Demonstration of HINTS Examination in a Normal Subject

In the acute vestibular syndrome - consisting of acute prolonged vertigo, spontaneous nystagmus, imbalance, nausea/vomiting, head motion intolerance which is typically due to vestibular neuritis or posterior fossa stroke - a 3 step test of ocular motor and vestibular function known as HINTS, has higher sensitivity to detect an acute stroke (<72 hours) as compared with MRI diffusion weighted imaging in the hands of a vestibular/eye movement subspecialist. HINTS stands for Head Impulse, Nystagmus, Test of Skew, and with a peripheral lesion (for example on the right), there should be a + head impulse test (HIT) to the right, left-beating unidirectional nystagmus (increasing in left gaze in accordance with Alexander's law), and no vertical refixation saccade with alternating cover testing (i.e., no skew deviation). A central etiology should be strongly suspected when HIT is negative AND/OR nystagmus is direction changing (gaze-evoked) AND/OR a skew deviation is present - i.e., if a "central" pattern is seen in any of the individual 3 tests, the etiology is central until proven otherwise. A labyrinthine stroke could theoretically fulfill all "peripheral" criteria, so adding a finger rub test of hearing at the bedside further increasing the test's sensitivity (with labyrinthine infarct, hearing loss is usually present), and this is known as HINTS "plus." Here the HINTS testing is performed on a normal asymptomatic volunteer. Please refer to: Newman-Toker DE, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013 Oct;20(10):986-96.