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

Abstract

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.

Acute Diagnostic Neurology: Challenges and Opportunities

“…Role models for successful collaboration-Recently, we have seen EM investigators successfully partner with neurologists 21 and the reverse. 22 We have also witnessed the landmark launch of a clinical research network devoted to neurologic clinical trials in the ED, 23 and the convening of an NIH Roundtable panel on neurologic emergencies. 24 Bidirectional successes in collaborative research and national research resources may provide role models and spark trainee interest.…”

“…By systematically identifying gaps, it will be possible to focus educational and quality improvement initiatives. Specific gaps might be addressed by the application of dedicated programs such as certification in use of specialized examination techniques (e.g., "HINTS" eye movement testing in dizziness 22 ). 3.…”

Types of diagnostic errors in neurological emergencies in the emergency department

“…All cases of missed cerebellar strokes in our study were due to cognitive errors or knowledge gaps, which further supports the need for increased education on this diagnosis. While radiology misreads accounted for several cases of missed cerebrovascular pathology, it is also important for clinicians to understand the limitations of even the most advanced neuroimaging tests in making these diagnoses, particularly in the early hours after an event [27][28][29][30].…”

Az akut vestibularis szindróma sürgősségi diagnosztikájával szerzett tapasztalatok

“…Az izolált AVS képében jelentkező perifériás és centrális vestibularis kór-képek elkülönítésére az úgynevezett HINTS-paradigmát dolgozták ki, amely magas specificitású és szenzitivitású, és 1A evidenciaszintű. A HINTS három oculomotoros tesztet foglal magába: 1. fejimpulzusteszt (head impulse test), 2. nystagmus vizsgálata, 3. a vertikális szemtengely-deviáció vizsgálata (test of skew), amely kiegészül a hallásvizsgálattal (HINTS plusz: akut halláscsökkenés detektálása) [8,9]. Centrális kórképre utal, ha a beteg fejimpulzustesztje negatív és/vagy nystagmusa centrális típusú, és/vagy skew deviációja van, és/vagy akut hallás-csökkenése alakult ki.…”