The HINTS exam

Summary

The HINTS exam is a diagnostic tool used to differentiate between vestibular neuritis and stroke in patients presenting with acute, ongoing vertigo. The exam includes three components: the nystagmus test, the test for vertical skew, and the head impulse test. Directional nystagmus, abnormal vertical skew deviation, and an abnormal head impulse test indicate vestibular neuritis, while the opposite findings suggest a stroke. The HINTS exam is only performed on patients with hours or days of continuous vertigo and spontaneous nystagmus. It should not be combined with the Dix-Hallpike test, which is used for shorter vertigo episodes.

Takeaways

• 😀 The HINTS exam is used to diagnose vestibular neuritis and rule out a stroke in patients with ongoing vertigo, nausea, and vomiting.
• 😀 The HINTS exam is particularly useful for patients who have persistent vertigo lasting for hours or days and display spontaneous nystagmus.
• 😀 The three components of the HINTS exam are the nystagmus test, the test of vertical skew, and the head impulse test.
• 😀 In the nystagmus test, fixation can suppress nystagmus, so it is important to remove fixation using a piece of paper to assess it accurately.
• 😀 Unidirectional nystagmus (does not change direction) is often seen in vestibular neuritis and is reassuring in a HINTS exam.
• 😀 Bidirectional or direction-changing nystagmus is concerning and can indicate a stroke or a brain problem.
• 😀 The test of vertical skew involves the cover-uncover test, where abnormal vertical eye deviation (skew) is worrisome in the HINTS exam.
• 😀 The head impulse test is used to identify nerve problems by checking for abnormal catch-up eye movements. An abnormal head impulse test is reassuring as it suggests a nerve issue rather than a brain problem.
• 😀 In a normal head impulse test, the eyes remain fixed on the target, indicating no nerve damage. A catch-up saccade (eye movement) is seen in abnormal tests and is indicative of a vestibular issue.
• 😀 A reassuring HINTS exam involves unidirectional nystagmus, no vertical skew, and an abnormal head impulse test, while a worrisome exam shows direction-changing nystagmus, abnormal skew test, or a normal head impulse test.

Q & A

What is the purpose of the Hints Exam?

The Hints Exam is used to differentiate between benign vestibular neuritis and more serious conditions like stroke in patients presenting with prolonged vertigo, nausea, vomiting, and spontaneous nystagmus.

When should the Hints Exam be performed?

The Hints Exam should be performed on patients who have ongoing vertigo lasting hours or days, accompanied by spontaneous nystagmus.

What are the key components of the Hints Exam?

The three key components of the Hints Exam are the Nystagmus Test, the Vertical Skew Test, and the Head Impulse Test.

How is the Nystagmus Test performed in the Hints Exam?

The Nystagmus Test involves observing the patient's eye movements in different directions. To eliminate fixation, a piece of paper is placed between the patient’s head and the wall, and their gaze is directed to the left and right to observe nystagmus.

What does unidirectional nystagmus indicate in the Hints Exam?

Unidirectional nystagmus is generally reassuring, as it is often associated with vestibular neuritis, which is a benign condition.

What does direction-changing nystagmus indicate in the Hints Exam?

Direction-changing nystagmus is concerning, as it may indicate a stroke, and thus warrants further investigation.

How is the Vertical Skew Test performed?

The Vertical Skew Test is performed using the cover-uncover test, where one eye is covered and uncovered to observe any vertical eye movements. Any abnormal vertical deviation of the eyes is worrisome.

What does an abnormal Vertical Skew Test indicate?

An abnormal Vertical Skew Test, where there is vertical eye deviation (one eye moving upward or downward), suggests a potential brain issue and can be indicative of a stroke.

What does an abnormal Head Impulse Test indicate?

An abnormal Head Impulse Test, where there is a 'catch-up' movement of the eyes when the head is turned rapidly, suggests a vestibular nerve problem, which is reassuring for a diagnosis of vestibular neuritis rather than a brain problem.

When would the Dix-Hallpike test be used instead of the Hints Exam?

The Dix-Hallpike test is used for patients with brief episodes of vertigo (around 30 seconds) triggered by head movements, typically indicating benign paroxysmal positional vertigo (BPPV). It should not be used in patients with continuous vertigo as seen in the Hints Exam.