Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta‐analysis

Abstract

Introduction Dizziness is a common complaint presented in the emergency department (ED). A subset of these patients will present with acute vestibular syndrome (AVS). AVS is a clinical syndrome defined by the presence of vertigo, nystagmus, head motion intolerance, ataxia, and nausea/vomiting. These symptoms are most often due to benign vestibular neuritis; however, they can be a sign of a dangerous central cause, i.e., vertebrobasilar stroke. The Head Impulse test, Nystagmus, Test of Skew (HINTS) examination has been proposed as a bedside test for frontline clinicians to rule out stroke in those presenting with AVS. Our objective was to assess the diagnostic accuracy of the HINTS examination to rule out a central cause of vertigo in an adult population presenting to the ED with AVS. Our aim was to assess the diagnostic accuracy when performed by emergency physicians versus neurologists. Methods We searched PubMed, Medline, Embase, the Cochrane database, and relevant conference abstracts from 2009 to September 2019 and performed hand searches. No restrictions for language or study type were imposed. Prospective studies with patients presenting with AVS using criterion standard of computed tomography and/or magnetic resonance imaging were selected for review. Two independent reviewers extracted data from relevant studies. Studies were combined if low clinical and statistical heterogeneity was present. Study quality was assessed using the QUADAS‐2 tool. Random effects meta‐analysis was performed using RevMan 5 and SAS 9.3. Results A total of five studies with 617 participants met the inclusion criteria. The mean (±SD) study length was 5.3 (±3.3) years. Prevalence of vertebrobasilar stroke ranged 9.3% to 44% (mean ± SD = 39.1% ± 17.1%). The most common diagnoses were vertebrobasilar stroke (mean ± SD = 34.8% ± 17.1%), peripheral cause (mean ± SD = 30.9% ± 16%), and intracerebral hemorrhage (mean ± SD = 2.2% ± 0.5%). The HINTS examination, when performed by neurologists, had a sensitivity of 96.7% (95% CI = 93.1% to 98.5%, I2 = 0%) and specificity of 94.8% (95% CI = 91% to 97.1%, I2 = 0%). When performed by a cohort of physicians including both emergency physicians (board certified) and neurologists (fellowship trained in neurootology or vascular neurology) the sensitivity was 83% (95% CI = 63% to 95%) and specificity was 44% (95% CI = 36% to 51%). Conclusions The HINTS examination, when used in isolation by emergency physicians, has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS.

Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review

“…Test sensitivity and specificity appear to be dependent on the level of experience and training of clinicians, and less experienced clinicians are more likely to miss subtle positive HITs 11,20,21 . HINTS validation studies have to date relied on ocular motor examinations conducted by neurologists or neuroophthalmologists 7 . To our knowledge, no previous study has examined the sensitivity and specificity of HINTS as conducted by ED physicians, although Vanni et al 22 describe high sensitivity and specificity among ED physicians who received additional training to perform a group of similar bedside ocular motor tests.…”

“…It has been proposed as a useful tool in EDs to improve diagnostic accuracy for patients with isolated dizziness 6 . However, most validation studies to date have studied the diagnostic accuracy of HINTS as performed by neurologists or otolaryngologists in high stroke prevalence populations 7 . What we do not know is whether the HINTS exam has similarly high sensitivity when performed by emergency physicians in the ED setting, where the prevalence of central causes of dizziness is much lower and where training in the use of the examination may be less consistent or intensive.…”

Telling friend from foe in emergency vertigo and dizziness: does season and daytime of presentation help in the differential diagnosis?

“…The same is true for some cases of isolated nodulus infarction and isolated vestibular nucleus infarction [13,17,18]. The HINTS test helped a lot to reduce the rate of misdiagnosis in the AVS population with 100% sensitivity and 96% specificity for stroke identification [11,26]. Several factors favor a central/stroke diagnosis.…”

“…Over the last years, algorithms have been suggested to distinguish between posterior circulation stroke and vestibular neuritis in AVS, i.e., in patients presenting with rotational vertigo, horizontal-rotatory spontaneous nystagmus, postural imbalance with directional falls, nausea, and vomiting. For clinical evaluation, the HINTS procedure (head impulse test, gaze evoked nystagmus, skew deviation) is now widely applied [11] but its usability is still under discussion [15,26]. In addition, there is growing evidence for predictive factors in non-AVS VD [35].…”

Barriers and Facilitators Affecting Implementation of a Clinical Decision aid for the Diagnosis of Acute Aortic Syndrome: A Qualitative Study

“…Acute aortic syndrome is a dangerous and di cult to diagnose condition for which a new, evidence-based clinical decision aid has been developed. 16 In this study, we identi ed the barriers and facilitators likely to in uence the implementation of the AAS clinical decision aid, with the goal of pre-emptively addressing barriers and reinforcing enabling factors. Using the theoretical domains framework to guide our analysis of physician responses allows the barriers identi ed to be linked to the speci c interventions most likely to facilitate behaviour change: that is, decision aid uptake and use.…”