An additional article was selected that assessed the 3 components of HINTS as well as vertical smooth pursuit, but allowed for calculation of the accuracy of the HINTS exam alone.Īrticle 1: Newman-‐Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Te-‐ hrani AS, Mantokoudis G, Hanley DF, Zee DS, Kattah JC. Three articles that speciFically addressed the diagnostic accuracy of the HINTS exam were identiFied. The bibliographies of relevant articles were searched for additional references. Original studies that reported sufFicient data to construct 2X2 contingency tables were cho-‐ sen for analysis.

Outcome: Diagnostic accuracy, morbidity or mortality related to misdiagnosisĪn advanced PubMed search was conducted using the terms “(HINTS OR oculomo-‐ tor OR vestibuloocular) AND (vertigo or dizziness),” limited to humans and the Eng-‐ lish language, resulting in 142 citations ( ). Intervention: Bedside oculomotor testing (HINTS exam)Ĭomparison: MRI, discharge diagnosis, follow-up diagnosis Population: Adults with new-‐onset, acute vertigo with otherwise non-focal neurologic exam You begin delving deeper to determine if this is something you should be using in your practice… SpeciFically, this test includes evaluation of horizontal Head Impulse testing, the direction of Nystagmus, and Test of ocular Skew deviation. A quick search of the literature identiFies something referred to as the “HINTS” exam, which involves oculomotor testing. On your way home the next morning, you be-‐ gin wondering if there are any aspects of the physical exam that can differentiate between peripheral and central causes of vertigo. When the patient does not improve after receiving oral me-‐ clezine and IV diazepam, you bite the bullet and transfer him to Barnes-‐Jewish for further evaluation by the stroke team. Your differential includes two main concerns: either the patient has vestibular neu-‐ ritis and should be treated symptomatically and discharged, or he has suffered a cerebellar stroke and requires transfer to a hospital with neurology consultation and MRI available. The remainder of his neurologic exam is normal. He has an abnormal Rom ‐ berg’s and is unable to stand or ambulate unassisted. Cerebellar exam – including finger to nose, heel to shin, and rapid alternating movements ‐ is otherwise normal. On exam, he has horizontal beating nystagmus. His past medical history includes hypertension and diabetes, controlled with amlodipine, metformin, and glyburide. He denies recent URI symptoms, hearing changes, focal weakness or numbness, or speech changes. He reports the vertigo has been constant, is worse with any change in head position, and is associated with nausea and imbalance. He managed to grab his cellphone and called 911.

He notes “I haven’t felt like this since college!” He reports becoming nauseated and vomiting several times, then getting up and “staggering” to his bed where he laid down and tried to “wait it out.” After several hours of constant vertigo, he attempted to get up to go to the bathroom and fell to the Floor. He was at home eating dinner 5 hours prior to arrival when he felt the room begin to suddenly, and violently, spin around him. While moonlighting in a small, community hospital one evening, you are presented with a 58 year-old gentleman complaining of vertigo.

Peripheral vertigo