The "HINTS" Examination in Vertigo

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Vertigo is a symptom, not a diagnosis. It presents a unique problem for many clinicians because it is symptomatic of a plethora of diagnoses, ranging from benign to immediately life threatening. The challenge of navigating vertigo becomes even more daunting when having to differentiate benign peripheral vertigo from potentially life-threatening central vertigo, which is frequently the result of a cerebellar stroke. CT scan is often the initial imaging modality when stroke is being considered but is notoriously insensitiveparticularly when it comes to the posterior fossamissing 60% to 90% of acute ischemic strokes in the brainstem or cerebellum.

Therefore, a rapid bedside test to help differentiate central from peripheral vertigo has great value in this situation. The Head Impulse, Nystagmus, and Test of Skew (HINTS) exam has been proposed as an excellent screening tool and is a three-part oculomotor test. If any portion of the test indicates a central etiology, the test is considered positive and further evaluation for stroke or other central pathology is warranted. A negative HINTS examination can rule out a stroke better than a negative MRI with diffusion weighted imaging (DWI) in the first 24 to 48 hours after symptom onset with a specificity of 96%.

The presence of any one of three clinical signsa normal head impulse test, direction-changing nystagmus, or a skew deviationsuggests central, rather than peripheral, vertigo in patients with an acute sustained vestibular syndrome.

The 3 components of the HINTS exam include:

  1. Head Impulse Test: Patients with peripheral vertigo will have abnormal (positive) head impulse testing, while patients with central vertigo typically have a normal (negative) head impulse test.
    • Reassuring Finding: abnormal (corrective saccade)
  2. Nystagmus: Patients with peripheral vertigo will have unidirectional, horizontal nystagmus, while patients with central vertigo can have rotatory or vertical nystagmus, or direction-changing horizontal nystagmus.
    • Reassuring Finding: unidirectional, horizontal
  3. Test of Skew: Alternate eye cover testing may reveal skew deviation in patients with central vertigo and should be absent in peripheral vertigo.
    • Reassuring Finding: no skew deviation

As providers, we are taught to evaluate the acutely "dizzy" patient by focusing on how the patient characterizes their dizziness. To wit: "What do you mean by dizzy?" This approach is limited by both the patients' ability to articulate their sensation, and our understanding of pattern recognition. In conclusion, the HINTS exam can be beneficial in ruling out central vertigo in patients with acute vestibular syndrome, provided it is performed by a clinician who can also reliably interpret the results. Become that clinician.

References
  • Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493.
  • Nelson JA, Viirre E. The clinical differentiation of cerebellar infarction from common vertigo syndromes. West J Emerg Med. 2009;10:273-277.
  • Tarnutzer AA , Berkowitz AL , Robinson KA , et al . Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183:E571-E592.
  • Kattah JC, Talkad A V., Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40:3504-3510.

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Filed under: Neurology , Miscellaneous

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