The evaluation and management of syncope have changed considerably in the past 2 decades. In the early 1980s, several investigators showed that the causes of syncope were often not identified, even after extensive testing.1,4- 8 Such findings in turn led to the use of other diagnostic modalities, such as EPS and HUTT, which have had great impact in patient evaluation when used in properly selected groups.9- 11,13 Whereas in earlier investigations the cause of syncope remained unknown in approximately 50% of cases, the use of EPS and HUTT have made it possible to diagnose as many as 90% of cases.9- 11 Unfortunately, despite the high cost of syncope evaluation,6,15- 16 our findings suggest insignificant changes in the pattern of evaluation. For example, neurologic tests, most notably brain CT scan, EEG, and carotid Doppler, which have been a mainstay in patient evaluation for many years, are still commonly used, although they are of low diagnostic yield in unselected patients.1,4- 8,13- 14,18- 19 In patients without focal neurologic findings or history consistent with (primary) seizures, these tests are of limited use.13- 14 Among current patients, abnormal findings on brain CT scans (11%) and EEG (17%) were rarely diagnostic (in 2% of cases for each modality). Similarly, carotid Doppler, performed in 185 patients (29%), was not diagnostic in any of the 19 patients (10%) with abnormal findings. To our knowledge, no study has examined the usefulness of carotid Doppler in patients with syncope, although in a study of syncope patients who had received permanent pacemakers, occlusive disease of uncertain significance was found in 3 of 46 cases.18 Our findings regarding the pattern of use and the diagnostic yield of various neurologic tests are similar to those of previous reports.19- 20 In a study of 297 consecutive patients (mean age, 69 years) admitted in 1993-1994, Blanck et al19 reported that 1 or more neurologic tests, which accounted for 15% of the total diagnostic charges, were performed in more than 50% of cases, yielding a possible diagnosis in only 3 cases. Nyman et al16 also found a similarly high use of low-yield neurologic tests in elderly patients with recurrent syncope undergoing evaluation in 1993. In a later study involving patients admitted in 1995-1996, Stetson and colleagues20 reported similar results, ie, nearly half of 100 randomly selected patients (from a total of 901) underwent some neurologic testing (brain CT scan, 40%), the results of which did not identify any cause of syncope. Blanck and colleagues19 noted that neurology consultations were obtained in only 53 patients (18%), indicating that most tests were requested by physicians other than neurologists. We noted a similar pattern, especially with respect to the use of brain CT scan (approximately 50% ordered by emergency department physicians) and carotid Doppler. One would expect that having a neurologist, far more capable of uncovering pertinent historical facts and focal neurologic abnormalities from a given patient, would reduce unnecessary tests; unfortunately, current and past data19 suggest that this may not be the case. In addition to being costly,15,19 an overemphasis on neurologic testing and diagnoses can lead to a delay in the identification (and proper treatment) of previously unrecognized cardiovascular causes of syncope.21 The length of stay was also longer (6 vs 5 days; P<.05) among patients who underwent neurologic evaluation, although other factors may have accounted for the difference. Encouraging, however, is the fact that fewer patients underwent brain CT scans (33% vs 61%; P<.01) and carotid Doppler (17% vs 35%; P<.01) in 1998 compared with 1994. On the other hand, there was no change in frequency of use of EEG (37% vs 32%), and there was a trend toward a greater use of brain MRI, probably reflecting its more widespread availability.