HINTS Examination in Acute Vestibular Neuritis: Do Not Look Too Hard for the Skew

Green, Kemar E.; Gold, Daniel R.

doi:10.1097/wno.0000000000001013

Cited by 18 publications

(19 citation statements)

References 19 publications

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“…The test of skew alone, regardless of the measuring method (cTS vs. vTS), had an overall low sensitivity and a moderate accuracy to predict a stroke. Although in the literature, there are many case reports [11][12][13][14] of skew deviation as a rare sign in peripheral deficits, to our knowledge, there is no study evaluating the prevalence of skew measured with VOG goggles in AUVP patients. In our study, the prevalence of a pathological vertical ocular misalignment was almost identical in both, AUVP and vestibular strokes.…”

Section: Discussionmentioning

confidence: 98%

Acute vestibular syndrome: is skew deviation a central sign?

et al. 2021

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Objective Skew deviation results from a dysfunction of the graviceptive pathways in patients with an acute vestibular syndrome (AVS) leading to vertical diplopia due to vertical ocular misalignment. It is considered as a central sign, however, the prevalence of skew and the accuracy of its test is not well known . Methods We performed a prospective study from February 2015 until September 2020 of all patients presenting at our emergency department (ED) with signs of AVS. All patients underwent clinical HINTS and video test of skew (vTS) followed by a delayed MRI, which served as a gold standard for vestibular stroke confirmation. Results We assessed 58 healthy subjects, 53 acute unilateral vestibulopathy patients (AUVP) and 24 stroke patients. Skew deviation prevalence was 24% in AUVP and 29% in strokes. For a positive clinical test of skew, the cut-off of vertical misalignment was 3 deg with a very low sensitivity of 15% and specificity of 98.2%. The sensitivity of vTS was 29.2% with a specificity of 75.5%. Conclusions Contrary to prior knowledge, skew deviation proved to be more prevalent in patients with AVS and occurred in every forth patient with AUVP. Large skew deviations (> 3.3 deg), were pointing toward a central lesion. Clinical and video test of skew offered little additional diagnostic value compared to other diagnostic tests such as the head impulse test and nystagmus test. Video test of skew could aid to quantify skew in the ED setting in which neurotological expertise is not always readily available.

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Section: Discussionmentioning

confidence: 98%

Acute vestibular syndrome: is skew deviation a central sign?

et al. 2021

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“…6,7 It is also important to note that in the evaluation of patients with the acute vestibular syndrome, 12 a pathologic OTR can be present in central lesions and acutely in peripheral vestibulopathies. 4,9…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3] During head tilt, the dynamic OCR is driven by inputs from the semicircular canals and otolith organs; it consists of a torsional nystagmus with slow phases away from and quick phases toward the direction of head tilt. 4 A sustained head tilt, however, results in a static OCR, which is typically 10%-25% of the head tilt. 1,2 This OCR response is mainly driven by otolith inputs through the projections from the labyrinths to the ocular motor nuclei (Figure 2A).…”

Section: Discussionmentioning

confidence: 99%

Pearls & Oy-sters: Vertical Diplopia and Ocular Torsion

et al. 2022

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We describe a case with torsional deviation of the eyes from a brainstem lesion. Torsional eye movement refers to changes in the position of the eyes in the roll plane around the visual axis. When the head is tilted laterally (that is, rolled towards the shoulder), the eyes roll in the opposite direction as part of the torsional vestibulo-ocular reflex known as the ocular counter-roll (OCR). Pathologies that affect the otolith-ocular pathway can lead to a torsional deviation of the eyes as part of the ocular tilt reaction (OTR) that also cause vertical deviation of the eyes (skew deviation) and head tilt. Lesions caudal to the pontomedullary junction (such as the labyrinth, eighth cranial nerve, or vestibular nucleus) result in an OTR with ipsiversive torsional deviation, whereas lesions rostral to the junction result in an OTR with contraversive torsional deviation. Furthermore, torsional deviation of the eyes in OTR is conjugate (incyclotorsion in the higher eye and excyclotorsion in the lower eye), whereas torsional deviation from ocular palsy in peripheral lesions is disconjugate (e.g., exyclotorsion only in the higher eye with superior oblique palsy). Therefore, the pattern of torsional eye deviation can be helpful in localizing the lesion. Several techniques including fundus photography, double Maddox rod testing, optical coherence tomography (OCT), and video-oculography are used to measure torsional eye position.

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“…In OTR, the head tilt and ocular torsion occur toward the lower eye. Even though a small SD is also observed in peripheral vestibular disorders [ 56, 80, 96 ] (e.g., in 24% according to a study on 53 patients with acute unilateral vestibulopathy [ 96 ]), it has been included as a part of an ocular motor assessment to discriminate central from peripheral causes of AVS [ 37, 73 ]. Pronounced SD may be specific (98.1%) for stroke detection when larger than 3.3° [ 96 ], but is not very sensitive since SD is found in only about one third of patients with acute unilateral brainstem infarctions (31%, n = 111) [ 14 ].…”

Section: Evaluation Of Vascular Vertigo/dizzinessmentioning

confidence: 99%

Vascular vertigo and dizziness: Diagnostic criteria

Kim

Newman‐Toker

Kerber

et al. 2022

VES

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This paper presents diagnostic criteria for vascular vertigo and dizziness as formulated by the Committee for the Classification of Vestibular Disorders of the Bárány Society. The classification includes vertigo/dizziness due to stroke or transient ischemic attack as well as isolated labyrinthine infarction/hemorrhage, and vertebral artery compression and subclavian steal syndromes. Vertigo and dizziness are among the most common symptoms of posterior circulation strokes. Vascular vertigo/dizziness may be acute and prolonged (≥24 hours) or transient (minutes to < 24 hours). Vascular vertigo/dizziness should be considered in patients who present with acute vestibular symptoms and additional central neurological symptoms and signs, including central HINTS signs (normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation), particularly in the presence of vascular risk factors. Isolated labyrinthine infarction does not have a confirmatory test, but should be considered in individuals at increased risk of stroke and can be presumed in cases of acute unilateral vestibular loss if accompanied or followed within 30 days by an ischemic stroke in the anterior inferior cerebellar artery territory. For diagnosis of vertebral artery compression and subclavian steal syndromes, typical symptoms and signs in combination with imaging or sonographic documentation of vascular compromise are required.

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HINTS Examination in Acute Vestibular Neuritis: Do Not Look Too Hard for the Skew

Cited by 18 publications

References 19 publications

Acute vestibular syndrome: is skew deviation a central sign?

Acute vestibular syndrome: is skew deviation a central sign?

Pearls & Oy-sters: Vertical Diplopia and Ocular Torsion

Vascular vertigo and dizziness: Diagnostic criteria

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