The HINTS Exam

HINTS Exam for Acute Vestibular Syndrome (AVS)

Kattah et a. Stroke. 2009 Nov;40(11):3504-10. doi: 10.1161/STROKEAHA.109.551234. Epub 2009 Sep 17

Determining if vertigo is from a peripheral or central cause can be perplexing.  You can use the HINTS exam to rule out a central cause of vertigo and avoid getting an MRI.

The HINTS exam

Head Impulse test, bidirectional Nystagmus, Test of Skew.

How to perform the exam?

Head Impulse test: vestibular-ocular motor test. Patient focuses on examiner.  Slowly displace head in either direction 20 degrees & rapidly rotate to midline.  Looking for any “slippage” off the visual target during rotation. No fixation saccade -> normal response -> in context of AVS, indicates problem due to stroke (vs. vestibular neuritis). Normal response = (+) sign

Nystagmus: Look for nystagmus on lateral gaze with patient focusing on object.   Nystagmus = (+) sign

Test of Skew: alternate covering each eye & look for re-fixation or movement of the eye in response -> skew deviation. Small horizontal re-fixations are normal.  Vertical re-fixations are abnormal. Skew deviation = (+) sign

Interpretation of HINTS exam: If any one of the following is positive, the test is positive (i.e. concerning for central etiology of vertigo).

The evidence -> 100% sensitivity and 96% specificity for central cause of AVS. More sensitive than early MRI for stroke.

Watch the Video Demonstration

HINTS Exam.pdf


One thought on “The HINTS Exam

  1. Fantastic site. Just for clarification purposes, the “N” of HINTS is always the confusing part for me. Gaze evoked nystagmus can be seen in both peripheral and central etiologies. My understanding is that the concerning sign for a central lesion would be bi-directional nystagmus – meaning right gaze causes right sided nystagmus (fast-beat to right) and gaze to the left would cause the nystagmus to change direction (fast-beat to left). This won’t always be present, but when it is, the etiology is not peripheral.

    Obviously vertical or rotatory nystagmus is concerning for a central lesion as well, but as far as the HINTS pneumonic goes, bi-directional nystagmus is what we’re looking for, if we’re concerned for a central etiology. Nystagmus in only one direction is usually consistent with peripheral, but certainly doesn’t rule out a central etiology by itself.

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