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.|
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