Acute Vertigo Evaluation

Use an acute vestibular syndrome (AVS) pathway when dizziness or vertigo is acute in onset, continuous for at least 24 hours, and accompanied by nausea or vomiting, head-motion intolerance, gait unsteadiness, and spontaneous nystagmus. AVS commonly persists for days to weeks and is caused most often by vestibular neuritis but may reflect brainstem or cerebellar ischemia. AHA Journals+3AHA JournalsQuantitative Video-Oculography to Help Diagnose Stroke in Acute Vertigo and DizzinessScienceDirectSeparating posterior-circulation stroke from vestibular neuritis with quantitative vestibular testingPubMedBedside Testing in Acute Vestibular Syndrome—Evaluating HINTS Plus and Beyond—A Critical ReviewPubMedProgress in the Study of Diagnostic Methods for Central Acute Vestibular Syndrome of a Vascular Cause

Treat AVS as a stroke-risk presentation rather than presuming a peripheral process from severe vertigo, vomiting, or inability to walk alone. Approximately 10% to 20% of spontaneous AVS presentations are stroke, and roughly one-quarter of high-risk AVS cohorts have brainstem or cerebellar stroke. AHA Journals+1AHA JournalsQuantitative Video-Oculography to Help Diagnose Stroke in Acute Vertigo and DizzinessAHA JournalsDiagnosing Stroke in Acute Dizziness and Vertigo

Do not apply HINTS to episodic positional vertigo or to a patient without spontaneous nystagmus. In patients meeting diagnostic criteria for benign paroxysmal positional vertigo (BPPV) without additional vestibular or neurologic findings, routine neuroimaging and additional vestibular testing are not recommended; central features should instead prompt brain MRI or thin-slice CT evaluation. Wolters Kluwer+1Wolters KluwerAcute vertigo: stroke or not? : Current Opinion in NeurologyPubMedVertigo in Clinical Practice: Evidence-Based Diagnosis and Treatment

In AVS with spontaneous nystagmus, perform horizontal head impulse testing, assess nystagmus in different gaze positions, and use prism cross-cover testing for ocular alignment. Add bedside hearing assessment for HINTS-plus because acute unilateral hearing loss can identify stroke involving arterial supply to the labyrinth. ScienceDirect+1ScienceDirectUsing “HINTS family” to diagnose stroke in the acute vestibular syndrome: A systematic review and meta-analysisPubMedHINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging - PubMed

Classify HINTS as central when any component is inconsistent with peripheral vestibular localization: a normal horizontal head impulse without corrective saccade, direction-changing or gaze-evoked nystagmus, or skew deviation. Vertical ocular misalignment on cross-cover testing is always suspicious for central pathology. ScienceDirect+1ScienceDirectUsing “HINTS family” to diagnose stroke in the acute vestibular syndrome: A systematic review and meta-analysisNeurologyHints to the H.I.N.T.S. Exam for Acute Vestibular Syndrome | Neurology Education

A peripheral-pattern examination requires an abnormal unilateral head impulse with corrective catch-up saccades, unidirectional nystagmus, and no skew deviation. Unidirectional nystagmus—particularly when following Alexander's law—and catch-up saccades after lateral head impulse typically imply peripheral pathology, but these findings must be interpreted as the complete HINTS pattern rather than in isolation. Neurology+1NeurologyHints to the H.I.N.T.S. Exam for Acute Vestibular Syndrome | Neurology EducationPubMedHINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging - PubMed

HINTS-plus increases protection against falsely labeling an AICA or labyrinthine artery infarct as vestibular neuritis. These infarcts can produce unilateral peripheral vestibular dysfunction, including reduced vestibulo-ocular reflex gain and catch-up saccades, on bedside and video head impulse testing. New unilateral hearing loss should therefore override reassurance from an otherwise peripheral-appearing head impulse result. BMJ+1BMJVideo head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study | BMJ Neurology OpenScienceDirectUsing “HINTS family” to diagnose stroke in the acute vestibular syndrome: A systematic review and meta-analysis

For AVS with any central HINTS-plus feature, obtain neuroimaging for posterior circulation stroke and do not dismiss central localization because early MRI is negative. MRI may miss 20% to 50% of posterior fossa infarctions within 48 hours, and reduced MRI sensitivity during the first 48 hours is specifically recognized for posterior circulation stroke. BMJ+1BMJVideo head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study | BMJ Neurology OpenPubMedCentral Vertigo - StatPearls - NCBI Bookshelf

A central HINTS result remains concerning regardless of early imaging findings. In prospective AVS evaluation, structured HINTS testing was reported to be more sensitive than early MRI diffusion-weighted imaging for posterior circulation stroke detection. BMJ+3BMJVideo head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study | BMJ Neurology OpenAHA JournalsQuantitative Video-Oculography to Help Diagnose Stroke in Acute Vertigo and DizzinessNeurologyHints to the H.I.N.T.S. Exam for Acute Vestibular Syndrome | Neurology EducationPubMedHINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging - PubMed

CT is limited for small brainstem infarction, whereas CT perfusion may improve diagnostic accuracy for acute posterior circulation stroke. Imaging should complement, rather than replace, serial neurologic assessment when the bedside phenotype remains central. BMJ+1BMJMaking a diagnosis in patients who present with vertigoAHA JournalsComputed Tomography Perfusion Deficit Volumes Predict ...

Vestibular neuritis is the most common cause of spontaneous AVS and produces objective unilateral peripheral vestibular dysfunction: reduced vestibulo-ocular reflex gain with catch-up saccades on head impulse testing, peripheral unidirectional nystagmus, and no skew deviation. BMJ+2BMJVideo head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study | BMJ Neurology OpenAHA JournalsDiagnosing Stroke in Acute Dizziness and VertigoNeurologyHints to the H.I.N.T.S. Exam for Acute Vestibular Syndrome | Neurology Education

Posterior circulation stroke can produce isolated vertigo or dizziness without obvious focal neurologic deficits, particularly when ischemia involves brainstem or cerebellar vestibular structures. This overlap drives frequent frontline misdiagnosis; posterior circulation strokes presenting with dizziness are missed initially in roughly 35% of cases. PubMed+1PubMedBedside Testing in Acute Vestibular Syndrome—Evaluating HINTS Plus and Beyond—A Critical ReviewPubMedProgress in the Study of Diagnostic Methods for Central Acute Vestibular Syndrome of a Vascular Cause

Do not equate a unilateral abnormal head impulse with vestibular neuritis in every patient. AICA infarction, labyrinthine artery ischemia, and vestibular nucleus infarction can each produce unilateral peripheral vestibular test abnormalities; integrate hearing loss, nystagmus pattern, skew, gait findings, and imaging rather than relying on the head impulse result alone. BMJBMJVideo head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study | BMJ Neurology Open

Activate a posterior circulation stroke evaluation pathway for AVS with any central HINTS-plus sign, acute unilateral hearing loss, or discordance between a seemingly peripheral examination and the overall neurologic presentation. Posterior circulation stroke can present with subtle findings, and delayed recognition is common when symptoms are mild, nonspecific, or transient. BMJ+2BMJVideo head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study | BMJ Neurology OpenPubMedBedside Testing in Acute Vestibular Syndrome—Evaluating HINTS Plus and Beyond—A Critical ReviewPubMedProgress in the Study of Diagnostic Methods for Central Acute Vestibular Syndrome of a Vascular Cause

Document whether spontaneous nystagmus was present before recording a HINTS result. Record the head impulse result on each side, whether nystagmus remains unidirectional or changes with gaze, the cross-cover test result, bedside hearing result, examiner training, and the time from symptom onset to MRI. This prevents a falsely reassuring label of “negative HINTS” when the test was applied outside AVS or incompletely performed. Wolters Kluwer+2Wolters KluwerAcute vertigo: stroke or not? : Current Opinion in NeurologyPubMedBedside Testing in Acute Vestibular Syndrome—Evaluating HINTS Plus and Beyond—A Critical ReviewPubMedHINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging - PubMed

When video head impulse testing is available, reduced vestibulo-ocular reflex gain and refixation saccades provide objective evidence of unilateral peripheral vestibular dysfunction. However, video testing does not independently exclude posterior circulation stroke because select AICA, labyrinthine artery, and vestibular nucleus infarcts can produce the same unilateral abnormality. BMJ+1BMJVideo head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study | BMJ Neurology OpenScienceDirectSeparating posterior-circulation stroke from vestibular neuritis with quantitative vestibular testing