E-Pearls of the Week: HINTS of Stroke

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July 8, 2013

HINTS of Stroke

The acute vestibular syndrome is characterized by rapid onset of vertigo, nausea, vomiting, gait instability, head motion intolerance, and nytagmus. This commonly encountered condition results from a variety of potential etiologies ranging from benign peripheral vestibular pathology such as labyrinthitis to more sinister central pathology such as brainstem stroke. Bedside evaluation showing normal head-impulse testing, direction-changing nystagmus on eccentric gaze, and skew deviation (i.e. Head Impulse, Nystagmus, Test of Skew; HINTS) has strong predictive value for brainstem stroke.  (1)  In contrast, bedside evaluation showing abnormal head-impulse test, unidirectional nystagmus, and absence of skew deviation excludes stroke better than an early negative MRI and strongly predicts peripheral pathology.  (2)


  1. Gold DR, Reich SG. Clinical reasoning: A 55-year-old woman with vertigo. A dizzying conundrum. Neurology 2012; 79: e146-152.
  2. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffuse-weighted imaging. Stroke 2009; 40: 3504-3510.

Submitted by Roy Strowd, M.D. Resident Physician, Wake Forest School of Medicine, Winston Salem, NC.

Dr. Strowd is a member of the Resident and Fellow Section of Neurology.

For more clinical pearls and other articles of interest to neurology trainees, visit Neurology. Visit the E-Pearl of the Week Archive. Listen to this week's Neurology Podcast


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