12.16 SFGH am report: Vertigo

Takeaway pearl: The HINTS exam consists of horizontal head impulse testing, nystagmus evaluation, and alternate eye cover test, and in studies was found to be more sensitive for stroke than early MRI in acute vertigo syndrome

  • HINTS exam: evidence it could be more sensitive for stroke than early MRI in acute vertigo syndrome
    • Horizontal head impulse testing: rapid head rotation by the examiner with the subject’s vision fixed on a nearby object (often the examiner’s nose).
      • Peripheral vertigo: expect a corrective saccade (positive test).
      • Central vertigo: no corrective saccade (negative test).
    • Nystagmus evaluation
      • Peripheral vertigo: unilateral fast phase, beats away from the affected side
      • Central vertigo: direction of the fast phase may change on eccentric gaze
    • Alternate eye cover
      • Peripheral vertigo: No skew deviation or ocular tilt (eye remains motionless)
      • Central vertigo: Frequent skew deviation (+/- ocular tilt)


Peripheral Central
Nystagmus Unidirectional, horizontal with torsional component; not vertical Can be any direction
other neuro signs absent often present
postural instability unidirectional instability, walking usually preserved severe instability
Deafness or tinnitus may be present absent


  • Vestibular neuritis:
    • typically begins over a few hours, peaks in the first day, then improves within days
    • preceded by a viral illness in <1/2 of patients


Kattah et al. HINTS to diagnose Stroke in the Acute Vestibular Syndrome. Three-step bedside oculomotor examination more sensitive than early MRI Diffusion-Weighted Imaging. Stroke. 2009; 40:3504-3510.


Evernote link: http://www.evernote.com/l/AoOPKxghuZpGObsgq18Vc0h-NjfsOrMytcE/


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