# Acute Vertigo Evaluation

Evaluate acute vertigo by syndrome and examination target, not symptom quality. In continuous vestibular symptoms with spontaneous nystagmus, trained HINTS-plus examination can identify central patterns that warrant stroke imaging and management despite an early negative MRI.

**Clinical question:** How should clinicians distinguish posterior circulation stroke from peripheral vestibular disease in acute vertigo?

Updated: 2026-09-15T21:22:30.426364+00:00

## What matters in practice
- Apply HINTS or HINTS-plus only to acute vestibular syndrome with spontaneous nystagmus; it is not interpretable when nystagmus is absent. [11][13]
- Any central HINTS finding—normal head impulse, direction-changing gaze-evoked nystagmus, or skew deviation—should be managed as possible posterior circulation stroke. [9][20][21]
- A peripheral-pattern abnormal head impulse does not exclude stroke when new unilateral hearing loss is present or when an AICA, labyrinthine artery, or vestibular nucleus infarct is possible. [1][9]
- Do not use a negative MRI obtained within 48 hours as the sole rule-out test for posterior fossa infarction when bedside findings remain central; early MRI may miss 20% to 50% of posterior fossa infarctions. [1][19]
- HINTS performance depends on examiner training; routine emergency-department use by untrained clinicians has not reproduced expert-level accuracy. [13]

## Identify acute vestibular syndrome before ordering a stroke workup

The examination and imaging strategy depend on timing, persistence, and observed eye findings.

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. [3][7][13][16]

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. [3][4]

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. [11][18]
- AVS phenotype: continuous symptoms, spontaneous nystagmus, nausea or vomiting, motion intolerance, and unsteady gait. [3][13][21]
- Positional/episodic phenotype: use positional assessment for BPPV rather than HINTS; obtain central nervous system imaging only when additional concerning features are present. [18]
- Transient vestibular symptoms are not AVS; posterior circulation transient ischemia remains a diagnostic challenge and should not be reassured by an inapplicable HINTS examination. [11]

*Syndrome selection determines whether HINTS is valid and what a result changes. [11][13][18]*

| Presentation pattern | Bedside approach | Immediate implication |
| --- | --- | --- |
| Continuous acute vertigo or dizziness with spontaneous nystagmus and gait instability | Perform HINTS-plus only if trained in the examination. [11][13] | A central result requires posterior circulation stroke evaluation. [9][20] |
| Triggered positional episodes meeting BPPV criteria | Use positional diagnostic assessment; do not use HINTS. [11][18] | Avoid routine imaging unless other signs or symptoms suggest a central cause. [18] |
| No spontaneous nystagmus | Do not interpret HINTS-plus. [11] | Use targeted neurologic and vestibular assessment based on the clinical syndrome. [13] |

## Interpret HINTS-plus as a three-sign central screen

A single nonperipheral component makes the examination central until proved otherwise.

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. [9][21]

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. [9][20]

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. [20][21]

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. [1][9]
- Normal head impulse in AVS: central pattern; evaluate for stroke. [9][20]
- Direction-changing nystagmus with gaze: central pattern; evaluate for stroke. [9][20]
- Skew deviation on cross-cover testing: central pattern; evaluate for stroke. [9][20]
- New unilateral hearing loss: HINTS-plus central warning, including possible labyrinthine ischemia. [1][9]
- All peripheral-pattern components must be present before calling the result peripheral. [20]

### Who should perform HINTS

Reserve HINTS and HINTS-plus for clinicians trained to elicit and interpret the ocular motor findings. Expert studies report high diagnostic performance, but routine emergency clinician use has not achieved the same results; this limits using an untrained examination to defer stroke evaluation. [13][14]

A meta-analysis of 11 HINTS studies reported sensitivity of 0.97 and specificity of 0.81 for stroke; HINTS-plus sensitivity was 0.99 and specificity 0.82. These estimates apply to appropriately selected AVS populations and do not validate use outside the syndrome or without examiner proficiency. [9]

*HINTS-plus interpretation in acute vestibular syndrome with spontaneous nystagmus. [1][9][20]*

| Component | Peripheral-compatible finding | Central warning finding | Action |
| --- | --- | --- | --- |
| Horizontal head impulse | Corrective catch-up saccade after lateral impulse. [20] | Normal response without corrective saccade. [9][20] | Central finding: pursue posterior circulation stroke evaluation. [9] |
| Nystagmus | Unidirectional nystagmus, especially following Alexander's law. [20] | Direction-changing or gaze-evoked nystagmus. [9][20] | Central finding: pursue posterior circulation stroke evaluation. [9] |
| Test of skew | No vertical ocular misalignment. [20] | Skew deviation on cross-cover testing. [20] | Central finding: pursue posterior circulation stroke evaluation. [20] |
| Hearing in HINTS-plus | No new unilateral hearing loss. [9] | New unilateral hearing loss, including with an abnormal head impulse. [1][9] | Consider AICA/labyrinthine ischemia and manage as possible stroke. [1][9] |

## Use MRI to confirm stroke, not to overrule a central bedside examination

Posterior fossa ischemia may be radiographically occult early after symptom onset.

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. [1][19]

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. [1][3][20][21]

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. [2][6]
- Central HINTS-plus with negative early MRI: continue stroke concern; reassess clinically and do not use the negative study as a stand-alone exclusion. [1][19]
- Normal imaging plus convincing peripheral HINTS pattern: supports peripheral localization only when the examination was performed in the correct AVS population by a trained clinician. [13][14]
- CT alone is insufficient reassurance for suspected small brainstem infarction. [2]

*Imaging limitations in suspected posterior circulation stroke. [1][2][6][19]*

| Test or result | Decision-relevant limitation | Clinical response |
| --- | --- | --- |
| MRI within 48 hours | May miss 20% to 50% of posterior fossa infarctions. [1] | Do not overrule central HINTS-plus findings. [1][19] |
| Noncontrast CT | Can be insensitive for small brainstem infarcts. [2] | Do not use a negative CT to dismiss persistent central concern. [2] |
| CT perfusion | May improve diagnostic accuracy in acute posterior circulation stroke. [6] | Consider as part of stroke imaging when available and clinically indicated. [6] |

## Distinguish vestibular neuritis from posterior circulation stroke

Peripheral findings support vestibular neuritis only after central warning signs have been actively excluded.

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. [1][4][20]

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. [13][16]

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. [1]
- Peripheral-compatible AVS: abnormal unilateral head impulse, unidirectional nystagmus, absent skew, and no new unilateral hearing loss. [1][20]
- Central-compatible AVS: any central HINTS sign, new unilateral hearing loss, or persistent clinical concern despite early negative MRI. [1][9][19][20]
- Isolated dizziness or vertigo does not exclude posterior circulation stroke. [13][16]

*Decision-focused comparison of vestibular neuritis and posterior circulation stroke in AVS. [1][9][13][20]*

| Finding | Vestibular neuritis pattern | Stroke concern | Next action |
| --- | --- | --- | --- |
| Head impulse | Reduced vestibulo-ocular reflex with corrective saccades. [1][20] | Normal head impulse, or abnormal impulse with new hearing loss. [1][9] | Normal impulse or hearing-loss exception: stroke evaluation. [1][9] |
| Nystagmus | Unidirectional pattern. [20] | Direction-changing or gaze-evoked pattern. [9][20] | Treat as central localization. [9] |
| Ocular alignment | No skew deviation. [20] | Skew deviation. [20] | Treat as central localization. [20] |
| Early MRI | Normal study may support peripheral diagnosis when examination is peripheral. [21] | Negative study does not exclude posterior fossa infarction within 48 hours. [1][19] | Continue stroke pathway if bedside findings are central. [1][19] |

## Escalate central patterns and document why HINTS was interpretable

The safest documentation links syndrome eligibility, individual eye findings, hearing, and imaging timing.

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. [1][13][16]

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. [11][13][21]

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. [1][7]
- Escalate: any central HINTS-plus component. [9][20]
- Escalate: new unilateral hearing loss in AVS, even with an abnormal head impulse. [1][9]
- Escalate: central bedside phenotype despite negative early MRI. [1][19]
- Use video head impulse testing as an objective adjunct, not a stand-alone stroke exclusion test. [1][7]

*Minimum documentation for an AVS evaluation using HINTS-plus. [1][11][13][21]*

| Documented item | Why it changes interpretation |
| --- | --- |
| Continuous AVS symptoms and spontaneous nystagmus | Establishes whether HINTS-plus was applicable. [11][13][21] |
| Head impulse, gaze nystagmus, and cross-cover results | Identifies the individual central or peripheral HINTS components. [9][20][21] |
| New unilateral hearing loss | Captures the HINTS-plus warning for labyrinthine/AICA ischemia. [1][9] |
| MRI timing from symptom onset | Determines the relevance of early false-negative posterior fossa imaging. [1][19] |

## References
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## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.