The HINTS Exam for Bedside Diagnosis of Central Causes of Dizziness
PICOTS:
- P = Patients presenting with acute vestibular syndrome
- I = HINTS examination
- C = Evaluation with MRI
- O = Diagnosis of central etiologies of vestibular syndrome
- T = Acute Setting (within 1 hour to 2 weeks)
- S = Emergency Department
Note: PICOTS stands for (P) for patient, (I) for intervention of interest, (C)
for comparison, (O) for outcome of interest, (T) for
timing, & (S) for setting.
Take Home Point(s):
- The HINTS (Head Impulse, Nystagmus and Test of Skew) exam should only be performed on patients with acute spontaneous vestibular syndrome. These include patients with ongoing continuous symptoms of vertigo/dizziness, gait unsteadiness, nausea or vomiting.
- The data supporting the HINTS exam is based on the examination being performed by a specialist or sub-specialist.
- A dangerous HINTS exam is more sensitive than MRI with DWI within the first 48 hours. Therefore, a dangerous HINTS exam should carry a high clinical suspicion for central etiologies even in the setting of a negative MRI within the first 2 days.
Summary:
Acute Vestibular Syndrome is
defined as continuous and unprovoked symptoms of dizziness or vertigo,
nystagmus, gait unsteadiness nausea or vomiting. These patients often present as a diagnostic
dilemma in the diagnosis of peripheral vs. central causes of these symptoms. The
HINTS (Head impulse, Nystagmus and Test of Skew) exam is a neurologic exam developed
to diagnose or exclude central etiologies of vertigo or dizziness in these
patients. It has been found to be both sensitive and specific in the diagnosis
of central vertigo when performed by a trained professional in the correct
patient population, and can even outperform MRI within the first 48 hours. In
much of the available literature the exam is performed by a trained
professional such as a neurologist, neuro-otologist or neuro-ophthalmologists. Unfortunately,
there is only limited data on the generalizability of these results to other
providers such as general or emergency physicians trained in the exam.
Author(s): Aaryn K. Hammond, MD - (Johns Hopkins School of Medicine)
Editor(s): Jeremiah Hinson, MD, PhD - (Johns Hopkins School of Medicine) and Dylan Kellogg, MD - (Arnot Ogden Medical Center)
Editor-in-Chief: Anthony J. Busti, MD, PharmD, FNLA, FAHA
Date Last Reviewed: May 2018
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