Does HINTS Miss Stroke?
April 3, 2020
Written by Clay Smith
The HINTS exam alone, when assessed by emergency physicians in patients with acute vestibular syndromes (AVS), was not sufficient to rule out a central cause for vertigo. Have a low threshold to obtain MRI in patients with AVS and stroke risk factors.
Why does this matter?
The HINTS exam has been touted as an effective and accurate way to detect vertebrobasilar stroke vs a peripheral vertigo syndrome. See the Newman-Toker article. In the hands of a neuro-ophthalmologist, that may be true. How do emergency physicians do with HINTS?
HINT – be careful with this
This was a meta-analysis of 5 studies of patients with vertigo who had a HINTS exam as part of the workup and CT or MRI as the gold standard. For studies with only neurologists or neuro-ophthalmologists performing the HINTS exam, pooled sensitivity and specificity were 96.7 (93.1-98.5) and 94.8 (91-97.1), respectively. However, the only study which included both emergency physicians and neurologists had lower sensitivity and specificity: 83.3 (63.1-93.6) and 43.8 (36.7-51.2), respectively. Overall, quality of the studies was low, with all at risk of several biases: verification bias, spectrum bias, and detection bias, all of which would inflate sensitivity and specificity.
Can emergency physicians accurately rule out a central cause of vertigo using the HINTS exam? A systematic review and meta-analysis. Acad Emerg Med. 2020 Mar 13. doi: 10.1111/acem.13960. [Epub ahead of print]
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