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A series of mysterious fainting spells leads to an unusual diagnosis.

Jennifer is a 65-year-old woman who presents with recurrent episodes of syncope over the past decade. She has had six events in the past 12 months, on a background of having at least 2-3 syncopal episodes each year.


The last episode led to severe facial trauma, including orbital fractures, due to a sudden drop to the floor shortly after dinner, and necessitated a hospital admission. She lives alone.

Investigations in the past have included 72-hour Holter monitoring, transthoracic echocardiogram, carotid artery Doppler ultrasound, brain MRI and tilt table testing.

They have all