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HINTS for stroke diagnosis?
Original research article: Krishnan,
Kailash, Kerolos Bassilious, Erik Eriksen, Philip M Bath, Nikola
Sprigg, Sigrun Kierulf Brækken, Hege Ihle-Hansen, Morten Andreas Horn,
and Else Charlotte Sandset. “Posterior Circulation Stroke Diagnosis
Using HINTS in Patients Presenting with Acute Vestibular Syndrome: A
Systematic Review.” European Stroke Journal, (April 2019).
doi:10.1177/2396987319843701. https://doi.org/10.1177/2396987319843701
HINTS for stroke?
Comment by Linxin Li
Acute vestibular syndrome (AVS) is
common and is often considered benign, but it is estimated that up to
one in four patients presenting with AVS could be suffering from
posterior circulation strokes.1 Given that brain scans, even
MRI brain, can have low sensitivity in the posterior fossa, bedside
predictors remain essential to differentiate central vs. peripheral
vestibulopathies.
In this issue of ESJ, Krishnan and
colleagues reported a systematic review looking at the sensitivity and
specificity of a quick bedside test in identifying posterior circulation
stroke in patients presenting with AVS – the Head
Impulse-Nystagmus-Test of Skew (HINTS) test.2
HINTS was first described in 2009 and is
a 3-step oculomotor examination. A positive HINTS test includes the
presence of any of the three signs: a normal horizontal head impulse
test, direction-changing nystagmus in eccentric gaze and eye skew
deviation.1
In this systematic review, 6 studies
involving 644 patients were included (mean age 58 years). All patients
were evaluated in emergency departments and MRI brain with
diffusion-weighted imaging was used in all studies as the gold
diagnostic standard. The pooled sensitivity and specificity using HINTS
to identify any stroke was 95.5% and 71.2% respectively. The overall
positive predictive value was 59.9% and negative predictive value was
97.2%. Of interest, among those with an imaging proven infarct, the most
common site was the cerebellum followed by the pons.
Whilst the authors confirms that HINTS
appears to be a reliable and effective bedside test in differentiating
acute posterior circulation stroke from peripheral vestibular causes in
patients presenting with AVS, several questions remain. Firstly, the
feasibility of performing the full HINTS in acutely unwell patients,
especially in patients at older ages, is unclear and whether a
simplified version of HINTS could be adopted in sick patients is yet to
be determined. For example, skew was shown to predict brainstem
involvement in AVS even when an abnormal horizontal head impulse test
falsely suggested a peripheral cause.1 Secondly, the
reproducibility of HINTS between specialists versus non-specialists
needs to be further validated. Lastly, although HINTS can be useful in
managing patients presenting with persistent AVS, comprehensive clinical
judgement remains crucial in the hyper-acute phase.
The full paper can be found at: https://doi.org/10.1177/2396987319843701
Reference
- Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the AVS: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40: 3504-10.
- Krishnan K, Bassilious K, Eriksen E, et al. Posterior circulation stroke diagnosis using HINTS in patients presenting with acute vestibular syndrome: a systematic review. European Stroke Journal 2019. DOI: 10.1177/2396987319843701
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