Template:HINTS Exam Procedure

The 3 components of the HINTS exam include:

1. Head impulse test of vestibulo-ocular reflex function
2. Observation for nystagmus in primary, right, and left gaze
3. Alternate cover test for skew deviation.

Head Impulse Test:

1. 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
2. Have patient fix their eyes on your nose
3. Move their head in the horizontal plane to the left and righ
4. When the head is turned towards the normal side the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target
5. 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
6. It is reassuring if the reflex is abnormal (due to dysfunction of the peripheral nerve)

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.
• Skew is also known vertical dysconjugate gaze and is a sign of a central lesion

1. Have pt look at your nose with their eyes and then cover one eye
2. Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.
3. Repeat with on each eye