HINTS, VERTIGO

BACKGROUND AND PURPOSE: Acute vestibular syndrome (AVS) typically manifests as isolated dizziness or vertigo with no apparent neurological impairments. However, distinguishing life-threatening stroke from innocuous peripheral vestibular lesions in the emergency room (ER) remains challenging. This study aimed to explore the ability of the head impulse-nystagmus-test of skew (HINTS) combined with truncal ataxia or ABCD2 score to differentiate stroke from peripheral vestibular disease in patients with AVS in the ER...

BACKGROUND: Dizziness is a common reason for people to seek medical care. Acute vestibular syndrome (AVS) is a specific type of dizziness, which can include severe vertigo, nausea and vomiting, nystagmus, or unsteadiness. Acute vestibular syndrome can be due to peripheral or central causes. It is important to determine the cause, as the intervention and outcomes differ if it is from a peripheral or central cause. Clinicians can assess for the cause using risk factors, patient history, examination findings, or advanced imaging, such as a magnetic resonance imaging (MRI)...

Background: Severe truncal ataxia associated with an inability to sit up without assistance (STA grade 3) is frequent in patients with central acute vestibular syndrome (AVS) involving the brainstem or cerebellum. When these patients have nystagmus, central HINTS excludes peripheral lesions; however, additional localization and lateralization signs are helpful, not only to resolve the peripheral versus central vestibular lesion dilemma, but to zero in on a precise lesion localization/lateralization to the lateral medulla, the most common ischemic lesion localization associated with an initially false-negative stroke MRI...

BACKGROUND: There are evidence-based bedside tests for diagnosing acute vertigo, but no evidence-based strategies to support clinicians in implementing them. The purpose of this study was to design an implementation strategy for treating acute vertigo by examining current facilitators and barriers to using these tests in the ED using the principles of implementation science. METHODS: A survey was developed using the Theoretical Domains Framework and Consolidated Framework for Implementation Research to examine barriers and facilitators for using HINTS+ (head impulse, nystagmus, test of skew, plus hearing) and Dix-Hallpike tests...

Vertigo/dizziness or balance disorders are among the most common patients complaints in emergency clinics. Up to 25% of them are potentially life-threatening, especially cardiovascular or cerebrovascular events. The combination of a careful history taking (triggers, duration of difficulties, associated symptoms) and the performance of a basic vestibular examination (nystagmus, oculomotor, head impulse test, positional maneuvers, standing and walking examination) leads to a reliable differentiation of central and peripheral vestibular etiology...

BACKGROUND: Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. OBJECTIVE OF THE REVIEW: This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence. DISCUSSION: PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors...

BACKGROUND: Vertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient...

Acute vertigo and dizziness are frequent presenting symptoms in patients in the emergency department. These symptoms, which can be subtle and transient, present diagnostic challenges because they can be caused by a broad range of conditions that cut across many specialties and organ systems. Previous work has emphasized the value of combining structured history taking and a targeted examination focusing on subtle oculomotor signs. In this review, we discuss various diagnostic bedside algorithms proposed for the acutely dizzy patient...

When acute vertigo occurs, the challenge for the medical practitioner lies in the focused assessment to find the cause of its symptoms. Especially in the case of central pathology, a fast diagnosis is essential for therapy. The h ead impulse, n ystagmus, t est of s kew (HINTS) protocol and the additional video head impulse test (VHIT) can distinguish between central and peripheral vestibular causes in the acute setting and thus help to set the right path for further evaluation and treatment. In this case, a patient with acute onset of vertigo presented with an unusual pattern in the VHIT...

Dizziness is a common but often diagnostically difficult condition. Clinicians should focus on the timing of the events and triggers of dizziness to develop a differential diagnosis because it is difficult for patients to provide quality reports of their symptoms. The differential diagnosis is broad and includes peripheral and central causes. Peripheral etiologies can cause significant morbidity but are generally less concerning, whereas central etiologies are more urgent. The physical examination may include orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, the Dix-Hallpike maneuver (for patients with triggered dizziness), and the HINTS (head-impulse, nystagmus, test of skew) examination when indicated...

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration...

OBJECTIVE: Acute dizziness/vertigo is usually due to benign inner-ear causes but is occasionally due to dangerous neurologic ones, particularly stroke. Because symptoms and signs overlap, misdiagnosis is frequent and overuse of neuroimaging is common. We assessed the accuracy of bedside findings to differentiate peripheral vestibular from central neurologic causes. METHODS: We performed a systematic search (MEDLINE and Embase) to identify studies reporting on diagnostic accuracy of physical examination in adults with acute, prolonged dizziness/vertigo ("acute vestibular syndrome" [AVS])...

PURPOSE: This study aimed to explore the differences in diagnosis (Dix-Hallpike test; the head impulse, nystagmus, and the test of skew [HINTS] procedures; imaging modalities; and audiological battery) and treatment (pharmacological treatments and the Epley maneuver) of acute vertigo (AV) by examining the perspectives of otolaryngologists, emergency physicians (EPs), and primary care physicians (PCPs). METHOD: A total of 123 physicians (otolaryngologists [ n = 40], EPs [ n = 41], PCPs [ n = 42]) were included in this study...

BACKGROUND: The management of dizziness and vertigo can be challenging in the emergency department (ED). It is important to rapidly diagnose vertebrobasilar stroke (VBS), as therapeutic options such as thrombolysis and anticoagulation require prompt decisions. OBJECTIVE: This study aims to assess the rate of misdiagnosis in patients with dizziness caused by VBS in the ED. METHODS AND RESULTS: The cohort was comprised of 66 patients with a mean age 56 years; 48% were women and 52% men...

BACKGROUND AND PURPOSE: Differentiating between peripheral and central aetiologies can be challenging in patients with acute vertigo, given substantial symptom overlap. A detailed clinical history and focused physical eye movement examination such as the HINTS eye examination appear to be the most reliable approach to identify acute cerebellar/brainstem stroke, outperforming even acute brain imaging. We have observed, however, that isolated vertigo of central cause may be accompanied by acute truncal ataxia, in the absence of nystagmus...

INTRODUCTION: Dizziness is a common scenario in the Emergency Departments (EDs). Among dizziness underlying causes, the posterior circulation stroke is especially relevant due to its mobimortality and concerning misdiagnosis rates. Therefore, we conducted this study to assess dizziness evaluation and baseline characteristics of patients with PS in the ED. METHODS: We conducted a 3-year retrospective observational study on PS cases confirmed by magnetic resonance imaging (MRI)...

OBJECTIVES: To separate posterior-circulation stroke (PCS) and vestibular-neuritis (VN) using quantitative vestibular tests. METHODS: Patients were prospectively recruited from the emergency room within 72 h of presentation. Video-nystagmography (VNG), three-dimensional video head-impulse testing (vHIT), vestibular-evoked myogenic potentials (VEMPs), and subjective visual-horizontal (SVH) were performed. RESULTS: There were 128 PCS and 134 VN patients...

BACKGROUND: Vestibular schwannomas are benign tumours for which various treatments are available. We performed a systematic review of prospective controlled trials comparing the patient-relevant benefits and harms of single-fraction stereotactic radiosurgery (sfSRS) with microsurgical resection (MR) in patients with vestibular schwannoma. METHODS: We searched for randomized controlled trials (RCTs) and non-randomized prospective controlled trials in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and study registries (last search: 09/2021) and also screened reference lists of relevant systematic reviews...

BACKGROUNDS: Diagnostics of a posterior circulation ischemia (POCI) in patients with acute vertigo is a challenging task. Recently, the combination of HINTS (Head Impulse, Nystagmus and Test of Skew) exam and ABCD2 has been recommended to identify stroke in these patients. Until now, studies regarding HINTS have mostly been tested on preselected patient groups and their results are only partially applicable to real clinical practice. AIMS: To compare the sensitivity and specificity of HINTS and ABCD2 and their combination in unselected acutely dizzy patients in the emergency department (ED) toward posterior circulation stroke detection...

BACKGROUND: History and physical examination are key features to narrow the differential diagnosis of central versus peripheral causes in patients presenting with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical examination findings. METHODS: This study involved a patient-intervention-control-outcome (PICO) question: (P) adult ED patients with vertigo/dizziness; (I) presence/absence of specific physical examination findings; and (O) central (ischemic stroke, hemorrhage, others) versus peripheral etiology...