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Vertigo - HINTS plus testing

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Indications

Vertigo (present for hours to days)

and

Nystagmus present (at time of assessment)

Contraindications (absolute in bold)

Acute trauma

Cervical spine disease

Vascular insufficiency (carotid or vertebrobasilar)

Limited neck mobility

Alternatives

Video-oculography as an inpatient (if available)

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Vertigo exacerbation

Vomiting

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Any bed space

Staff

Procedural clinician

Equipment

None

Positioning

Patient sitting

Clinician sitting directly facing patient

Medication

Nil

Sequence (nystagmus testing)

Ask patient to look straight ahead (primary gaze)

Observe patient for nystagmus, noting the direction of the fast beat

Place piece of white paper lateral to patient and ask them to look to the side (20 degrees lateral gaze)

Do not ask the patient to fix vision on anything such as your finger (fixation will reduce nystagmus)

Observe patient for nystagmus, noting the direction of the fast beat

Sequence (vertical skew testing)

Ask patient to look straight ahead fixing their vision on your nose (primary gaze)

Cover one of the patient’s eyes with your hand (without touching the face)

Uncover the eye and cover the other eye

Observe each eye as it is uncovered for any vertical movement (they should remain motionless)

Sequence (head impulse testing)

Explain the test and ask the patient to relax their neck as much as possible

Ask patient to look straight ahead at your nose (primary gaze)

Hold onto the patient’s skull with both hands

Rotate patient’s head smoothly 20 degrees laterally in both directions (encouraging them to relax)

Briskly move the patient’s head from 20 degrees lateral back into the midline

Observe for a catch-up saccade (inability to maintain fixation with correction after movement ends)

Repeat this on both sides, randomly altering speed and direction to avoid patient anticipation

Sequence (finger rub hearing test)

Ask patient to look straight ahead at your nose

Rub your fingers together close to each ear

Ask the patient to tell you when you are rubbing your fingers

Note any new unilateral hearing deficit

Post-procedure care

Define testing as either:

A HINTS exam suggesting vestibular neuritis (all four signs present):

Unidirectional horizontal nystagmus, and

No vertical skew, and

Peripheral head impulse test (catch-up saccade indicating peripheral cause), and

No new hearing loss

Or

A HINTS exam suggesting stroke (any of these signs present):

Direction-changing or vertical nystagmus, or

Vertical skew, or

Central head impulse test (no catch-up saccade), or

New hearing loss

Tips

HINTS exam is worth doing well (it’s more sensitive than early MRI for detecting stroke in spontaneous vertigo)

Fixation block techniques (white paper above) are sometimes required to pick up spontaneous nystagmus

Describe the head impulse test results as peripheral or central (avoiding the confusion of positive and negative test results)

The Dix-Hallpike test is only performed on patients without spontaneous nystagmus

The Dix-Hallpike test and HINTS exam are never performed on the same patient

Discussion

There are two pathologies to consider in patients who present with nystagmus and vertigo lasting hours or days.

Vestibular neuronitis (peripheral nerve pathology)

Stroke (central pathology)

Most patients with vertigo lasting hours to days will have vestibular neuritis (peripheral nerve cause), but some of these patients have suffering a stroke (central cause). The HINTS (Head Impulse test, test of Nystagmus, Test of Skew) exam is used to reliably diagnose vestibular neuritis and so rule out stroke.

Nystagmus with an acute peripheral vestibular lesion is horizontal, present in primary position and beats in one direction regardless of eye positions. The slow phase is caused by the hypoactive affected ear, which moves gaze towards the lesion and away from fixation. The fast phase is the correction of gaze. By convention the direction of nystagmus is described as the direction of the fast beat. Peripheral nystagmus increases in gaze towards the direction of the fast phase and decreases in gaze towards the direction of the slow phase (Alexander’s law). A peripheral head impulse test (catch-up saccade) is seen when moving the head to midline from the affected side.

For example, the peripheral nerve lesion in right vestibular neuronitis will cause nystagmus always to the left (fast beat), which is exacerbated when looking left, and displays a catch-up saccade when moving the head from 20 degrees right into the midline. The test of skew will be normal.

The bedside hearing test was added to HINTS in 2013 as the HINTS plus exam. Hearing loss due to an anterior inferior cerebellar artery (AICA) stroke may rarely present with signs of a peripherally head impulse test with new hearing loss. There are only two reported instances of isolated AICA infarcts showing an abnormal head impulse test. Both these patients also had direction-changing horizontal nystagmus and positive skew and may have been picked up by a HINTS exam alone.

Peer review

This guideline has been reviewed and approved by the following:

Emergency Care Institute

Dr Peter Johns, Assistant Professor, Department of Emergency Medicine, University of Ottawa

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Produced with and reviewed by Dr Peter Johns, Assistant Professor, Department of Emergency Medicine, University of Ottawa.

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Furman JM, Barton JJS. Evaluation of the patient with vertigo. In: UpToDate. Waltham (MA): UpToDate. 2020 Feb 11. Available from: https://www.uptodate.com/contents/evaluation-of-the-patient-with-vertigo

eTG complete. Melbourne: Therapeutic Guidelines; 2017 Nov. Stroke and vertigo. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=stroke-and-vertigo

Kattah JC. Use of HINTS in the acute vestibular syndrome. an overview. Stroke Vasc Neurol. 2018;3(4):190-196. Published 2018 Jun 23. doi:10.1136/svn-2018-000160

Kattah JC. Update on HINTS Plus, with discussion of pitfalls and pearls. J Neurol Phys Ther. 2019;43 Suppl 2:S42-S45. doi:10.1097/NPT.0000000000000274

Nelson JA, Viirre E. The clinical differentiation of cerebellar infarction from common vertigo syndromes. West J Emerg Med. 2009;10(4):273-277.

Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. 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. doi:10.1161/STROKEAHA.109.551234

Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20(10):986-996. doi:10.1111/acem.12223

Edlow JA, Newman-Toker D. Using the physical examination to diagnose patients with acute dizziness and vertigo. J Emerg Med. 2016;50(4):617-628. doi:10.1016/j.jemermed.2015.10.040

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