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 u201Cslippageu201D 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 of the 1 of the 3 is positive, the test is positive.

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

Watch the Video Demonstration http://content.lib.utah.edu/cdm/singleitem/collection/ehsl-dent/id/6