What if I told you that I think that patient you just sent home with vertigo may have been a missed cerebellar stroke? Would you be dialing risk management or could you tell me all of the reasons why I'm wrong? Isolated vertigo without other neurological findings can't be a stroke, right? That is true, if you are doing the right exam, but if you are just doing your standard ED neuro screening exam then you might be missing serious pathology. In this episode of the EMCrit podcast, I discuss how to perform the tests that will differentiate a peripheral cause of continuous vertigo from a cerebellar stroke.
Drs. David Newman-Toker & Jorge Kattah, neurologists at John Hopkins, have done a ton of work on this topic. They have created an mnemonic for the exam you should be doing on all of your patients with continuous vertigo (as opposed to positional, intermittent vertigo, i.e. BPPV). Benign positional paroxysmal vertigo is not ED critical care. Continuous vertigo, also known as acute vestibular syndrome, may be. The mnemonic is HiNTS.
Hi for head impulse testing, or head thrust testing.
N for nystagmus to remind you to look for direction-changing or vertical nystagmus
TS for test of skew.
I will discuss what all of these terms mean and how to perform the exams in the podcast.
Here is the HiNTS article.
Here is a link to another study by the same authors on head impulse testing.
Here is a fantastic review article by James A. Nelson on the topic.
Here is a video demonstrating the exam with positives and negative examples.
Update
Insanely good systematic review on Dizzy Stroke Patients (CMAJ 2011;183(9):E571)
and maybe the best review on Vertigo ever!
Until this one was published: Edlow's New Approach to Dizziness (Emerg Med Clin North Am. 2016 Nov;34(4):717-742.)
and here is a fantastic journal club from EM Journal Club with Dr. Newman-Toker himself
and another Edlow et al. J Emerg Med 2018;54(4):469
TiTrATE (Neuro Clin 2015;33:577)
Additional New Information
Yes, there is an app for that
but now, we just use the apple ios' inbuilt camera app in slomo mode
More on EMCrit
EMCrit 316 – Vertigo and Posterior Stroke with Peter Johns(Opens in a new browser tab)
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Scott- Outstanding lecture at Cornell yesterday! I was pretty excited about David Newman-Toker’s papers at first, but I’ve become a little skeptical that the HiNTS battery — in particular, the head impulse test — is a magic test for detecting cerebellar stroke in the ED. First of all, the head impulse test is tricky to perform, and the result you’re looking for is quite subtle. And although all the papers say you can perform the test in the presence of spontaneous nystagmus, a non-expert (like me) has a lot of trouble distinguishing nystagmus from a catch-up saccade when the patient’s… Read more »
Dr. Lappin, pleasure to meet you. Your comments are well received. I think I need to clarify for which patients I believe the HINTS exam is important. If the patient has any worrisome signs, i.e. the profound ataxia you mention, a headache in association with the vertigo, any hard neurological findings, then no HINTS necessary–pursue MRI and neurological consultation. Or if the patient is elderly (though I don’t have an exact age cut-off for when that designation begins), they probably should be admitted with neurology onboard regardless of the HINTS exam. But if you have a patient with isolated vertigo… Read more »
I completely agree with your strategy of using HiNTS as a fail-safe. My experience is a little different — my BPPV patients don’t (and, I think, shouldn’t) have head-motion intolerance in the horizontal plane (for example, the head-impulse test), only in the vertical plane (the Dix-Hallpike). As for the patients with continuous vertigo, many are — as you say — comfortable by the time they come to us. The ones who aren’t are a real challenge for any sort of testing. In general, I think the difficulty with vertigo comes at the beginning, with the basics. A lot of docs… Read more »
Ahem. Rather a specialty subconsultant?
Peter Johns- Ottawa, Emergency Physician
This comment hits a lot of nails on the head.
Doing HINTS on people with short episodes of vertigo, and Dix-Hallpike on people with with ongoing vertigo and spontaneous nystagmus is a huge problem.
One thing which I have grown to appreciate is that horizontal canal BPPV is not uncommon. In fact I’ve seen 3 in the past few months. These patients may in fact get very vertiginous with simple head turning in the horizontal plane. See my video on my youtube channel on how to diagnose and treat it.
very nice job Peter
http://www.youtube.com/watch?v=BNP5UiRlmiU
I just posted this video of a HINTS exam with positive head impulse test using an iphone 5S, in 120 FPS mode. The catch up saccade is unmistakable in the slowed down portion of the video. I think this might be the best positive head impulse ON THE INTERNET!
Newman-Toker’s review paper emphasizes the challenge in defining the dizziness type; aka dizziness type is an imprecise metric and ED patients are unreliable historians. So how then does one appropriately identify a patient as having “acute vestibular syndrome” (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait)? Doing so must involve clarifying a patient’s dizziness type, no? In my view, the methodology described in “HINTS to Diagnose Stroke in the Acute Vestibular Syndrome” study lacks clarity. How exactly were the acute vestibular syndrome patients selected? I see Newman-Toker’s view in his review that defining dizziness as being nearly a fruitless effort on… Read more »
Scott, Quick question. In some recent shadowing experience I did in the emergency room here in Tennessee. The doctor and I were discussing vertigo and different ways to determine things clinically. He had heard of this “head impulse test” in medical school and had used it a couple of times in residency but has since moved away from it. When I asked about his reasoning he said “Next patient we get in here with vertigo, try that test. They may vomit all over your shoes and scrubs, and I can promise you they are not going to be very happy… Read more »
Dax,
Key is not to try this test on the positional vertigo patients. The folks with continuous vertigo generally won’t vomit on you from moving their head around especially in the horizontal plane. Try the test on a bpv patient and you may need a change of scrubs, but it’s not helpful on these patients anyway.
scott
Scott, I just came across this Podcast and was somewhat surprised by it. Why was critical analysis of these tests left out? No mention of sensitivity and specificity and how applicable and helpful these tests would be to the undifferentiated vertiginous patient who presents to the ED? I can’t imagine attempting to order an MRI or transfer a patient to get one based on a NORMAL head impulse test. Skew deviation may-be predictive of badness, but I’d be very surprised if this was your only abnormal neurologic symptom, as in you were about to send the patient home, but hold… Read more »
Marcus,
Thanks for writing! Before I respond, let me ask a few questions:
1. Did you listen to the podcast? I am not asking that to be flip; many folks comment just based on the blogpost?
2. Did you read the linked articles discussing the test characteristics?
3. Did you read the comments above?
4. Could you tell us your level of training and type of practice?
Question: as I understand the HiNTS exam, it is to be applied to patients with continuous vertigo/symptoms, not intermittent. However, a consulting neurologist opined the opposite. Could you clarify? Thanks
Scott, I agree with the other comments – I’m not sold on the HINTS exam. The head impulse testing I find is difficult to perform and probably likely to send a lot of “normal” exams to imaging they don’t need in the low risk population we see which doesn’t appear to be the population HINTS was studied in. This post I found makes the argument well in reference to an updated study of HINTS.
http://emnerd.com/adventure-veiled-lodger
The population we are talking about need something more, whether it be neuro consultation, MRI, or HINTS. AVS can not be ruled out as badness with a standard neuro exam. I’m not sure what you mean by low risk, I think you may be mixing in other forms of vertigo.
You may also want to evaluate:
PMIDs 21153732, 19762709, 18541870
the studies are certainly interesting but I do wonder how well it will be applied by the average ED doc around the world compared to a few select neurologists well experienced in its use. The head impulse testing in particular is a difficult test.
Oh wow, this happened to me as a student in IM, pt admitted for dizziness and I was assigned to him. Someone got the wrong idea this pt came in freq for dizziness but I checked his record and never admitted for anything neuro related. I gave him a full neuro and the cerebellar tests were off but Romberg was positive. But overall because of the he himself said he flet like he was walking like a drunk person when trying to get to the hospital and I agreed when I saw him try to walk it seemed more significant… Read more »
Good stuff, trust your gut
Again, thanks so much for bringing up head impulse test to minds of ED clinicians. I’ve been using this test for quite some time and I still get blank deer-eye looks from other docs when I talk about this test and I’d say most docs still are not aware of this test. The HINTS test and its study from 2009 was ok but I find the CMAJ article too biased with one of the authors blatantly promoting the HINTS test and study throughout the article. It’s a very small study still and the 100% sensitivity touted really shouldn’t be taken… Read more »
great article; will link to it in the post.
Vertigo chair treatment or therapy is an excellent indigenous attempt has been made in designing and fabrication of a rotary chair with high technology mechanism to operate for treatment and rehabilitation of vertigo causes. The main aim of this chair is to avoid or minimize taking the medicine & eliminate giddiness.
Any potential for LVO amenable to thrombectomy in patients with isolated vertigo? I often have patients with only vertigo, and very mild ataxia that could be consistent with a peripheral cause outside. When they are outside of the tPA window and I’m left wondering if these patients require stroke alerting for expedited CTA and perfusion. Alternatively, is this presentation inconsistent with a lesion amenable to Neuro interventional therapy?
The neurologist that does endovascular clot retrieval and/or lyses at my hospital are not keen on treating patient who have vertigo only. Even patients who can’t walk they say often improve without these interventions. Obviously if something on vascular imaging is getting them excited they might do it. But most of them have more than isolated vertigo.