Posterior circulation stroke diagnosis using HINTS in patients presenting with acute vestibular syndrome: A systematic review

Abstract

Acute vestibular syndrome-vertigo, nausea/vomiting, nystagmus and gait unsteadiness-is common, and differentiating posterior circulation stroke from a peripheral cause can be challenging. The National Institute of Health Stroke Scale (NIHSS) does not include acute vestibular syndrome, and early computed tomography scanning cannot rule out acute ischaemia. A positive Head Impulse-Nystagmus-Test of Skew (HINTS) test suggests posterior circulation stroke in acute vestibular syndrome when any of three signs are present: normal horizontal head impulse, gaze-direction nystagmus or eye skew deviation. This systematic review examined the accuracy of positive HINTS in identifying posterior circulation stroke in acute vestibular syndrome patients. Methods: We searched MEDLINE (1966 to 21 December 2017), EMBASE (1980 to December 2017), Web of Science and scanned bibliographies. Two authors independently screened relevant articles and extracted data. We included studies where HINTS was used to identify posterior circulation stroke with diagnosis confirmed using magnetic resonance imaging. Findings: Six studies (n ¼ 644 patients) were identified. Acute stroke was confirmed in 200 (31.1%) patients. There was a 15-fold increased risk of posterior circulation stroke in patients with positive HINTS test compared to those with no abnormality (RR: 15.84, 95% CI: 5.25-47.79). For any stroke, the pooled sensitivity was 95.5% (95% CI: 92.6-98.4%) and specificity was 71.2% (95% CI: 67.0-75.4%). Discussion and Conclusion: The data suggest that the HINTS test as one element of clinical evaluation is useful to differentiate posterior circulation stroke from peripheral causes in acute vestibular syndrome. Further studies are needed to validate HINTS as a clinical prediction tool in emergency department settings and selection of patients for reperfusion treatment.

Benign paroxysmal positional vertigo in the emergency department: An observational study of an Australian regional hospital's acute clinical practice

“…CTB in detection of acute ischemic stroke is reported to be only 16% sensitive compared with other bedside battery of physical examinations such as HINTS, with reported sensitivity of 100% and specificity of 96% 15,16 . A systematic review concerning the screening for stroke with the bedside battery of examinations, reported a pooled sensitivity of 95.5% (95% CI 92.6–98.4%) and specificity of 71.2% (95% CI 67.0–75.4%) 17 . However, neither the HINTS assessment nor imaging provide any diagnostic value in the diagnosis of BPPV; where the bedside vestibular examination is normal aside from provocative manoeuvres and imaging is normal regardless of modalities.…”

Telling friend from foe in emergency vertigo and dizziness: does season and daytime of presentation help in the differential 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].…”

Isolated vertigo in a young male, HINTS examination and vertebral artery dissection in emergency department – A case report

“…[ 5 ] A meta-analysis examined the accuracy of positive HINTS in identifying PCS in acute vertigo patients and found it to be 95.5% (95% CI: 92.6–98.4%) sensitive and 71.2% (95% CI: 67.0–75.4%) specific. [ 6 ]…”