neurology emergency

HINTS Exam for Stroke vs Vestibular Neuritis

Head Impulse, Nystagmus, Test of Skew (HINTS). 3-step bedside eye examination to differentiate posterior fossa stroke from peripheral vestibular disorder in acute vestibular syndrome. More sensitive than early MRI.

Head Impulse Test (HIT)*

Rapidly turn the head 10–15° to each side while the patient fixes on the examiner's nose. A corrective saccade means the vestibulo-ocular reflex is impaired (peripheral sign); no saccade (a normal test) is the central sign in acute vestibular syndrome.

Nystagmus pattern*

Test in primary gaze and with gaze deviation left and right

Skew Deviation (Alternate Cover Test)*

Cover one eye then quickly switch to the other; observe for vertical refixation movement

Score interpretation

All Peripheral Signs — Likely Vestibular Neuritis 0

All 3 signs peripheral — likely viral vestibular neuritis/labyrinthitis

→ Vestibular suppressants (prochlorperazine); vestibular rehabilitation; antivirals if herpes zoster suspected; discharge if stable

Central Sign Present — Stroke Must Be Excluded 1–3

≥ 1 central sign — posterior fossa stroke must be excluded (Kattah 2009: 100% sensitive and 96% specific for stroke in acute vestibular syndrome with ≥ 1 stroke risk factor).

→ URGENT: IV access; blood glucose; CT head (insensitive for posterior fossa stroke in first 24–48h); MRI DWI brain urgently; neurology review; stroke pathway

Interpretation bands for the HINTS Exam. Apply clinical judgement and local guidance.

References

Kattah JC et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways

Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.

Score interpretation

References

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