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(Stroke. 2009;40:3504.)
© 2009 American Heart Association, Inc.

Original Contributions

HINTS to Diagnose Stroke in the Acute Vestibular Syndrome

Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging

Jorge C. Kattah, MD; Arun V. Talkad, MD; David Z. Wang, DO; Yu-Hsiang Hsieh, PhD, MS David E. Newman-Toker, MD, PhD

From the Department of Neurology (J.C.K., A.V.T., D.Z.W.), The University of Illinois College of Medicine at Peoria and the Illinois Neurological Institute at OSF Saint Francis Medical Center, Peoria, Ill; and the Department of Neurology (D.E.N.-T.), and Department of Emergency Medicine (Y.H.H.), The Johns Hopkins University School of Medicine, Baltimore, Md.

Correspondence to David E. Newman-Toker, MD, PhD, Assistant Professor, Department of Neurology, The Johns Hopkins Hospital, Pathology Building 2-210, 600 North Wolfe Street, Baltimore, MD 21287. E-mail toker{at}jhu.edu

Background and Purpose— Acute vestibular syndrome (AVS) is often due to vestibular neuritis but can result from vertebrobasilar strokes. Misdiagnosis of posterior fossa infarcts in emergency care settings is frequent. Bedside oculomotor findings may reliably identify stroke in AVS, but prospective studies have been lacking.

Methods— The authors conducted a prospective, cross-sectional study at an academic hospital. Consecutive patients with AVS (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with 1 stroke risk factor underwent structured examination, including horizontal head impulse test of vestibulo-ocular reflex function, observation of nystagmus in different gaze positions, and prism cross-cover test of ocular alignment. All underwent neuroimaging and admission (generally <72 hours after symptom onset). Strokes were diagnosed by MRI or CT. Peripheral lesions were diagnosed by normal MRI and clinical follow-up.

Results— One hundred one high-risk patients with AVS included 25 peripheral and 76 central lesions (69 ischemic strokes, 4 hemorrhages, 3 other). The presence of normal horizontal head impulse test, direction-changing nystagmus in eccentric gaze, or skew deviation (vertical ocular misalignment) was 100% sensitive and 96% specific for stroke. Skew was present in 17% and associated with brainstem lesions (4% peripheral, 4% pure cerebellar, 30% brainstem involvement; ², P=0.003). Skew correctly predicted lateral pontine stroke in 2 of 3 cases in which an abnormal horizontal head impulse test erroneously suggested peripheral localization. Initial MRI diffusion-weighted imaging was falsely negative in 12% (all <48 hours after symptom onset).

Conclusions— Skew predicts brainstem involvement in AVS and can identify stroke when an abnormal horizontal head impulse test falsely suggests a peripheral lesion. A 3-step bedside oculomotor examination (HINTS: Head-Impulse—Nystagmus—Test-of-Skew) appears more sensitive for stroke than early MRI in AVS.

Key Words: cerebrovascular accident • diagnosis • neurologic examination • sensitivity and specificity • vertigo