Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis

Newman‐Toker, David E.; Kattah, Jorge C.; Alvernia, Jorge E.; Wang, David Z.

doi:10.1212/01.wnl.0000314685.01433.0d

Cited by 330 publications

(300 citation statements)

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“…As in a prior analysis, 25 eye movement approaches (with examinations obtained prior to imaging in almost all patients) matched or outperformed initial MRI-DWI. Initial MRI sensitivity in this series was 86.7% (n = 98 of 113, 95% CI = 79.5% to 92.1%).…”

Section: Demographic and Clinical Characteristics Are Shown Inmentioning

confidence: 56%

“…Because this was a secondary analysis of preexisting data from an ongoing longitudinal study, [25][26][27] no a priori sample size or power calculations were performed to choose the study sample. It was known from prior work, 26 however, that a sample roughly half that used here produced adequately narrow confidence intervals (CIs) around sensitivity and specificity estimates to inform robust clinical decision-making.…”

Section: Discussionmentioning

confidence: 99%

“…[25][26][27] We recruited patients with at least 1 hour of acute, persistent, continuous vertigo or dizziness with spontaneous or gaze-evoked nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness (i.e., AVS), presenting within 1 week of symptom onset. Patients would have been excluded if their symptoms abated prior to 24 hours (n = 0), as the technical definition of AVS requires 24 hours of symptoms.…”

Section: Study Setting and Populationmentioning

confidence: 99%

“…We also assessed two prospectively defined HINTS modifications: one with known greater specificity 8 (one-item head impulse test alone 25 ), the other with hypothesized greater sensitivity 18 (four-item HINTS "plus," which adds new hearing loss as a predictor of inner ear or cochlear nucleus stroke, 8,19,33,34 rather than labyrinthitis, which is uncommon in AVS 26 ). Hearing loss was judged to be present only if bedside examination (finger rubbing) detected a clear right-left asymmetry and the patient confirmed the deficit to be new.…”

Section: Outcome Measuresmentioning

confidence: 99%

“…23,24 A well-studied expert approach relies on differentiating transient from persistent dizziness and then examining eye movements. 8,18,[25][26][27] Most stroke patients present with persistent symptoms. Acute vestibular syndrome (AVS) is a well-defined clinical syndrome 28 of acute, persistent vertigo or dizziness lasting days to several weeks with associated nausea or vomiting, head motion intolerance, gait unsteadiness, and nystagmus.…”

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confidence: 99%

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HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

315

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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Section: Demographic and Clinical Characteristics Are Shown Inmentioning

confidence: 56%

Section: Discussionmentioning

confidence: 99%