Journal Club Summary: HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and D
The Article: “HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness”
Newman-Toker et al., Academic Emergency Medicine 20.10 (2013): 987-995.
The Idea: Is the HINTS exam (head impulse, nystagmus type, test of skew) a better way to screen for CVA as the cause of acute vestibular syndrome (AVS) than the ABCD2 (age, blood pressure, clinical features, duration, diabetes) score?
This study examined 190 patients at a single stroke referral center that had acute vestibular syndrome (defined as acute, persistent vertigo or dizziness with nystagmus, nausea, head motion intolerance, and new gate unsteadiness) and also one or more stroke risk factor. The HINTS exam was compared to the ABCD2 score and neuroimaging to determine the best screening test to identify patients with CVA as the etiology of acute vertigo. The Findings:
The HINTs exam had a sensitivity of 96.5% and a specificity of 84.4% for stroke in AVS patients. The ABCD2 score was found to be 61.1% sensitive and 62.3% specific. Early MRI was 86.7% sensitive in this population. Using the 1-step HIT rule (head impulse test only) increased specificity to 87.0% but decreased sensitivity. Using the HINTS “plus” rule (HINTS plus new hearing loss) increases sensitivity to 99.1% but decreases specificity.
The Takeaway: The HINTS exam, when used in the correct clinical context, is sensitive and specific for stroke, outperforms a risk factors-based scoring system, and is a valuable tool to help risk-stratify patients with acute persistent vertigo.