HINTS EXAM

Grace Blankenhagen, SPT

What is the HINTS exam?

■ Purpose:
– Assess for central vestibular involvement1,2
– Assess presence of stroke1,2
– Ability to predict brainstem stroke2
■ 3 Components:
– Head Impulse
– Nystagmus
– Test of Skew
Head Impulse1,3

■ Can be done in seated or supine

– Supine is best for complete relaxation of cervical muscles
■ Have patient fixate on something
– Volunteer your nose
■ Passively rotate their head side to side
■ Initiate a quick turn
■ Assess for loss of target
Head Impulse- Interpreting Results1,3

■ Peripheral Vestibular Dysfunction

– Loss of target + corrective saccade
– Due to impaired VOR reflex
– Considered “positive” or “abnormal”
– Is ideal result- indicates peripheral involvement
■ Central Vestibular Dysfunction
– Loss of target and no corrective saccade
– Considered “negative” or “normal”
– Indicates central involvement when VOR reflex is intact and complaints of
vertigo are present
Nystagmus1,2

■ Assess for nystagmus in eccentric gaze

■ Peripheral Involvement
– Unidirectional
– Horizontal
■ Central Involvement
– Multidirectional
– Can be horizontal, vertical, or rotational
Test of Skew1

■ Seated or Supine
■ Cover one eye with paper or your hand
■ Instruct patient to keep eyes open and focused on something
■ Quickly remove your hand and observe for motion
■ Peripheral Involvement
– No movement of covered eye
■ Central Involvement
– Vertical or torsional movements of covered eye to correct
What is Test of Skew1,2

■ Central involvement typically has an imbalance between

right and left side gravity sensing function
■ Leads to vertical malalignment in eyes
■ Covering/uncovering the eye causes them to realign which
can be observed
■ Pathological ocular tilt reaction
Recap:

■ Reassuring Exam:
– Loss of target with corrective saccade
– Unidirectional, horizontal nystagmus in eccentric gaze
– Test of skew normal with no motion in eye

■ Concerning Exam (any one of the following):

– Loss of target with no corrective saccade or no loss of target
– Multidirectional, vertical, or rotational nystagmus in eccentric gaze
– Test of skew abnormal for vertical or torsional motion in covered eye
*central lesions may also present with unilateral hearing loss2
Which Patients are Appropriate?

■ Perform on patients with hours or days of continuous vertigo

and spontaneous nystagmus
Example3

■ https://www.youtube.com/watch?v=1q-VTKPweuk
References

1. Weingart S. Take a HINTS. Emergency Physicians Monthly. 2015.

http://epmonthly.com/article/take-a-hints/. Accessed November 15, 2017.
2. Kattah JC, Talkad AV, Wang DZ, Hsieh YU, Newman-Toker DE. HINTS to diagnose
stroke in the acute vestibular syndrome. Stroke. 2009;40:3504-3510. doi:
https://doi.org/10.1161/STROKEAHA.109.551234.
3. Johns P. The HINTS exam in vertigo. Available at:
https://www.youtube.com/watch?v=1q-VTKPweuk. Accessed November 15, 2017.
Questions?

Retrieved from: http://draconicmagazine.com/articles/david-s-pumpkins