EBQ:HINTS Exam

Under Review Journal Club Article

Kattah, J. et al. "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(11):3504–3510.
PubMed Full text PDF

Clinical Question

Is the HINTS exam (Head-Impulse—Nystagmus—Test-of-Skew) more sensitive for diagnosing stroke than early MRI diffusion-weighted imaging in Acute Vestibular Syndrome?

Conclusion

A negative HINTS examination can rule out a stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onset with a specificity of 96%.

Major Points

• The 3 components of the HINTS exam include: head impulse test of vestibulo-ocular reflex function; observation for nystagmus in primary, right, and left gaze; alternate cover test for skew deviation.

• Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.

• Initial MRIs are falsely negative in 12% and can prove misleading out to 48 hours after symptom onset.

Inclusion Criteria

At least one stroke risk factor: smoking, hypertension, diabetes, hyperlipidemia, atrial fibrillation, eclampsia, hypercoagulable state, recent cervical trauma, prior stroke or myocardial infarction.

Exclusion Criteria

A history of recurrent vertigo with or without auditory symptoms