Template:HINTS Exam Procedure
The 3 components of the HINTS exam include:
|HINTS Test||Reassuring Finding|
|Head Impulse Test||Abnormal (corrective saccade)|
|Test of Skew||No skew deviation|
Head Impulse Test
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 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 corrective saccade to re-fixate on the visual target 
- 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
- It is reassuring if the reflex is abnormal (due to dysfunction of the peripheral nerve)
- Observation for nystagmus in primary, right, and left gaze
- No nystagmus (normal) or only horizontal unilateral nystagmus is reassuring
- Any other type of nystagmus is abnormal, including 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