Template:HINTS Exam Procedure: Difference between revisions

Latest revision as of 17:03, 8 October 2023

Inclusion Criteria

HINTS exam should only be used in patient with acute persistent vertigo, nystagmus, and a normal neurological exam.
HINTS exam, when done correctly, has high sensitivity and specificity in distinguishing peripheral vs central etiologies of vertigo
Note that the original study was done by neuro-ophthalmologists in a differentiated patient base. This exam has not been studied in a large ED population yet

The 3 components of the HINTS exam include:

HINTS Test	Reassuring Finding
Head Impulse Test	Abnormal (corrective saccade)
Nystagmus	Unidirectional, horizontal
Test of Skew	No skew deviation

Always use correct terminology; "HINTS negative" does not convey a clear interpretation. State "HINTS central" or "HINTS peripheral" as suggested in literature
- If able, specify the exact exam finding as shown by chart above

Head Impulse Test

Test of vestibulo-ocular reflex function

Have patient fix their eyes on your nose
Move their head rapidly in the horizontal plane to the left and right
- When the head is turned towards the normal side, the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target
- When the head is turned towards the affected side, the vestibular ocular reflex fails and the eyes make a visible corrective saccade to re-fixate on the visual target ^[1]^[2]
- Normally, a functional vestibular system will identify any movement of the head position and instantaneously correct eye movement accordingly so that the center of the vision remains on a target.
  - This reflex fails in peripheral causes of vertigo affecting the vestibulocochlear nerve unilaterally; thus, failure of the reflex unilaterally is reassuring (since the cause is peripheral)
- Note that in central causes of vertigo, test may show normal reflex response OR failure of the reflex BILATERALLY

Nystagmus

Observation for nystagmus in primary, right, and left gaze
- No nystagmus (normal) or only horizontal unilateral nystagmus (fast direction only in one direction) is reassuring
- Any other type of nystagmus is abnormal, including vertical or bidirectional nystagmus

Test of Skew

Have patient look at your nose with their eyes and then cover one eye
Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.
Repeat with on each eye
- Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.
- Skew is also known vertical dysconjugate gaze and is a sign of a central lesion

↑ Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493
↑ Kuo CH, Pang L, Chang R. Vertigo - part 1 - assessment in general practice. Aust Fam Physician. 2008;37(5):341-7

[1] Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493

[2] Kuo CH, Pang L, Chang R. Vertigo - part 1 - assessment in general practice. Aust Fam Physician. 2008;37(5):341-7

[1]

[2]

@@ Line 1: / Line 1: @@
-'''The 3 components of the HINTS exam include:'''
+====Inclusion Criteria====
-#Head impulse test of vestibulo-ocular reflex function
+*HINTS exam should only be used in patient with acute persistent vertigo, nystagmus, and a normal neurological exam.
-#Observation for '''nystagmus''' in primary, right, and left gaze
+*HINTS exam, when done correctly, has high sensitivity and specificity in distinguishing peripheral vs central etiologies of vertigo
-#Alternate cover '''test for skew deviation'''.
+*Note that the original study was done by neuro-ophthalmologists in a differentiated patient base. This exam has not been studied in a large ED population yet
+====The 3 components of the HINTS exam include:====
+{| {{table}}
+| align="center" style="background:#f0f0f0;"|'''HINTS Test'''
+| align="center" style="background:#f0f0f0;"|'''Reassuring Finding'''
+|-
+| Head Impulse Test||Abnormal (corrective saccade)
+|-
+| Nystagmus||Unidirectional, horizontal
+|-
+| Test of Skew||No skew deviation
+|}
+*Always use correct terminology; "HINTS negative" does not convey a clear interpretation. State "HINTS central" or "HINTS peripheral" as suggested in literature
+**If able, specify the exact exam finding as shown by chart above
-'''Head Impulse Test:'''
+====Head Impulse Test====
-#Normally, a functional vestibular system will identify any movement of the head position and rapidly correct eye movement accordingly so that the center of the vision remains on a target. This reflex fails in peripheral causes of vertigo effective the vestibulocochlear nerve
+''Test of vestibulo-ocular reflex function''
 #Have patient fix their eyes on your nose
-#Move their head in the horizontal plane to the left and righ
+#Move their head rapidly in the horizontal plane to the left and right
-#When the head is turned towards the normal side the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target
+#*When the head is turned towards the normal side, the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target
-#When the head is turned towards the affected side, the vestibular ocular reflex fails and the eyes make a corrective saccade to re-fixate on the visual target <ref>Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493</ref><ref>Kuo CH, Pang L, Chang R. Vertigo - part 1 - assessment in general practice. Aust Fam Physician. 2008;37(5):341-7</ref>
+#*When the head is turned towards the affected side, the vestibular ocular reflex fails and the eyes make a visible corrective saccade to re-fixate on the visual target <ref>Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493</ref><ref>Kuo CH, Pang L, Chang R. Vertigo - part 1 - assessment in general practice. Aust Fam Physician. 2008;37(5):341-7</ref>
-#It is reassuring if the reflex is ''abnormal'' (due to dysfunction of the peripheral nerve)
+#*Normally, a functional vestibular system will identify any movement of the head position and instantaneously correct eye movement accordingly so that the center of the vision remains on a target.
+#**This reflex fails in peripheral causes of vertigo affecting the vestibulocochlear nerve unilaterally; thus, failure of the reflex unilaterally is reassuring (since the cause is peripheral)
+#*Note that in central causes of vertigo, test may show normal reflex response OR failure of the reflex BILATERALLY
+====Nystagmus====
+#Observation for '''nystagmus''' in primary, right, and left gaze
+#*No nystagmus (normal) or only horizontal unilateral nystagmus (fast direction only in one direction) is reassuring
+#*Any other type of nystagmus is abnormal, including vertical or bidirectional nystagmus
-'''Test of Skew'''
+====Test of Skew====
-*Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.
+#Have patient look at your nose with their eyes and then cover one eye
-*Skew is also known vertical dysconjugate gaze and is a sign of a central lesion
-#Have pt look at your nose with their eyes and then cover one eye
 #Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.
 #Repeat with on each eye
+#*Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.
+#*Skew is also known vertical dysconjugate gaze and is a sign of a central lesion