Template:HINTS Exam Procedure

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

Head Impulse Test

Test of vestibulo-ocular reflex function

  1. Have patient fix their eyes on your nose
  2. 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 [1][2]
    • 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)

Nystagmus

  1. 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

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