Where does the HiNTS exam fit into the ED evaluation of vertigo? A talk prepared for Emergency Medicine residents.

1. David A. Marcus
@EMIMDoc
LIJ Emergency Medicine – 12/2/2015
Dizzying HiNTS in the E.D.

2. Oh Doc, I’m dizzy…
28 y/o F
non contributory PMHx
dizzy for one day, nausea and vomiting.

3. Oh Doc, I’m dizzy…
85 y/o M
h/o Diabetes
p/w mild dizziness for 2 days, nausea.

4. Oh Doc, I’m dizzy…
52 y/o F
Healthy
“My head is light” (not heavy) x 6 hours
Needs help walking

5. Oh Doc, I’m dizzy…
65 y/o M
DM, CAD/CABG
Dizziness x 24 hrs
Photophobia, mild headache.

6. Oh Doc, I’m dizzy…
38 y/o F
Non contributory PMHx
Vertigo x 36 hours
Nausea and vomiting, reduced hearing

7. The Plan
 Spinning, dizziness, lightheadedness, oh my!
 Central vs Peripheral – Is that a thing?
 Taking it to the bedside
 A neuro-ophthalmologist says what?
 We will not be discussing the place of CT in
vertigo evaluation.

8. Spinning, dizziness, lightheadedness, oh my!
One man’s tree is another man’s bush…
15-20% of people with
vertigo will describe it
using other terms,
even with repeat
questioning, and may
use different terms for
same Sx within 1
encounter.

9. I’m Dizzy
 One of the most common ED complaints
 Tremendous DDx

10. Central vs Peripheral – Is That a Thing?
Yes. But first:
Benign Parox. Positional Vertigo
• N/V, Nystagmus, Head motion
intolerance
• Paroxysmal
• Positional
• Triggered by movement (vertical)
• < 1 minute
• Able to walk
• Dx: Dix Hallpike Maneuver
Torsional/Vertical Nystagmus
• Tx: Epley Maneuver/Meds
Acute Vestibular Syndrome
• N/V, Nystagmus, Head motion
intolerance
• Usually, acute onset
• Extended duration
• Unsteady gait

11. Central vs Peripheral – Is That a
Thing?
3% of all isolated vertigo = stroke
20% of posterior CVA have no neuro deficits
10% of cerebellar infarcts have only vertigo

12. Central vs Peripheral – Is That a Thing?
Acute Vestibular Syndrome (not BPPV)
Peripheral AVS:
1. Vestibular Neuritis/Labyrinthitis
(most)
2. Menierre’s Disease
(uncommon)
- Vertigo + Cochlear Sx
3. Trauma/Post Op
4. Schwannoma
Central AVS:
1. Cerebellar Infarct/Hemorrhage
2. Migrainous Vertigo
3. Meds/Tox
4. Demyelinating Disease (MS,
etc)
5. Trauma/Post Op
6. Masses (CPA tumors, etc)

13. Taking it to the Bedside
1. Sudden, maximal at onset
(though may not seem as
severe as BPPV)
2. Unable to ambulate without
assistance due to ataxia
3. Focal neuro deficits
4. New, acute occipital headache
5. Direction changing nystagmus
6. Intact Head Impulse Test
Red flags for Acute Vestibular Syndrome

14. Taking it to the Bedside
If:
Then:

15. Taking it to the Bedside
If no:
Then:

16. A neuro-ophthalmologist says
what?
 Originally published by Dr. David Newman-
Toker et al.
 Proponents argue that the HiNTS Exam
can help differentiate central vertigo from
peripheral vertigo in AVS.
 Use for patient with AVS without red flags,
who are at moderate-high risk of stroke

17. A neuro-ophthalmologist says
what?
 Hi – Head Impulse (VOR intact)
 Normal is ABNORMAL (central)
 N – Nystagmus
 Bidirectional or gaze evoked is ABNORMAL
(central)
 TS – Test of Skew
 Vertical skew is ABNORMAL (central)

18. Video on: http://emcrit.org/?powerpress_pinw=765-podcast
A neuro-ophthalmologist says
what?

19. A neuro-ophthalmologist says
what?
 The data:
 Kattah: ED; Vertigo, N/V, Gait Ataxia, +/-
Nystagmus; At least 1 risk factor
 Chen: ED; Vertigo, N/V; At least 1 risk factor
 Newman-Toker HiNTS vs ABCD2: ED; Vertigo,
Nystagmus, N/V, Gait imbalance, head motion
intolerance; At least 1 risk factor.
 Newman-Toker HiNTS: Specialized, small. Same
inclusions; At least 1 risk factor.
ALL exams done by trained Neuro, or Neuro-Ophth.
Mostly on admitted pts.

20. A neuro-ophthalmologist says
what?
•Up to 100%
sensitive and 96%
specific for CVA
•Better than MRI <
48 hours of Sx
•Methodological
concerns
•Unclear how fits
into practice
• Can’t rule out CVA

21. Taking it to the bedside
 Head Impulse testing can be difficult – here’s
a Trick of the Trade from Dr. Scott Weingart:
http://emcrit.org/procedures/iphone-hit/

22. The Bottom Line
 BPPV vs AVS
 Central vertigo may have less nausea and vomiting,
may be better tolerated.
 Red flags for AVS  MRI
 Sudden, maximal at onset
 Unable to ambulate without assistance d/t Ataxia
 Focal neuro deficits
 New, acute occipital headache
 Abnormal HiNTS exam
 HiNTS for symptomatic AVS without red flags
 Apply in “at risk” population
 Not a “rule-out” tool yet, extension of neuro exam
 Abnormal? MRI
 Normal? Decision based on clinical picture

23. Recommended Reading
 Cohn, B. Can Bedside Oculomotor (HINTS) Testing
Differentiate Central From Peripheral Causes of
Vertigo? Ann Emerg Med. 2014;64:265-268.
http://www.ncbi.nlm.nih.gov/pubmed/24530107
 Spiegel, R. The Adventure of the Veiled Lodger.
Posted on EMNerd, Oct 21, 2013.
http://emnerd.com/adventure-veiled-lodger
 Seemungal, BM, Bronstein AM. A practical approach
to acute vertigo. Pract Neurol 2008; 8: 211–221.
http://pn.bmj.com/content/8/4/211.abstract

24. Additional Citations
 Nelson, JA, Viirre, E. The Clinical Differentiation of
Cerebellar Infarction from Common Vertigo
Syndromes. West J Emerg Med. 2009;10(4):273-
277.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791
733/
 Petrosoniak, A. Boring Question: Dizzy, need a
few HINTS? Posted on BoringEM, 8/11/14.