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Posterior Circulation Stroke vs No Big Deal (THE HINTS EXAM)

Anand Swaminathan, MD FAAEM and Evie Marcolini, MD
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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EM:RAP 2017 September Written Summary 760 KB - PDF

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Ian L., Dr -

Interesting needs training .
Would be nervous Head Impulse test 70 year old OA neck .

Peter Johns, M.D. -

Like every new experience, it becomes easier to perform and interpret with practice.
The movement needs to go from 20 degrees off neutral to neutral. No one will be harmed by this. It is helpful if you first move their head slowly back in forth until it is clear their neck muscles are relaxed.

Robert M. H., M.D. -

will the head impulse test be abnormal in a normal person w/o vertigo?

Anand S., M.D. -

Robert - this is where the terminology falls apart a bit. Evie and I have an upcoming segment on the topic clarifying all of this a little bit.
If the patient doesn't have ongoing vertigo, they will be able to maintain fixation without a catch up saccade. This is concerning for a central cause. But, of course, your patient doesn't haver vertigo so now, you've got a concerning result in an asymptomatic patient. This stresses the reason that the HiNTS exam should ONLY be applied to those with ongoing vertigo. The point of the test is to differentiate between a peripheral cause of constant vertigo like vestibular neuritis or a central cause like a cerebellar stroke.

Peter Johns, M.D. -

To quote David Newman-Toker from his comment on Kerber's study . "Stroke risk stratification in acute dizziness
presentations . A prospective imaging-based study" . Neurology® 2015;85:1869–1878

His quote is this: "HINTS should only be applied in AVS patients with nystagmus."

The HIT is designed to demonstrate a problem with the vestibular nerve (vestibular neuritis). It will normal in (most) people with stroke, people with BPPV or normal people.

glenn b. -

I'm with Ian - in the handful of times I've tried to do head impulse, granny just doesn't tolerate me jerking her head: she closes her eyes with the sudden movement, and typically gives me an "oh dear" or an "oh my" with it.

Peter Johns, M.D. -

Use just 20 degrees of movement from lateral to midline and most people tolerate it very well.

Michael M. -

Are there recommended videos to demonstrate how to do this?

Anand S., M.D. -

Michael,
Here are some great ones from David Newman Toker: https://www.youtube.com/watch?v=Wh2ojfgbC3I

and from Peter Johns:

https://www.youtube.com/watch?v=1q-VTKPweuk&t=255s

Charles Haviland M. -

I've heard rumors that smooth pursuit can suppress nystagmus and that we should attempt to elicit it with saccadic and pursuit testing. Thoughts?

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