In a patient with continuous vertigo and spontaneous nystagmus, each HINTS component is reassuring in the opposite way to what intuition suggests. An abnormal head impulse — a corrective catch-up saccade — points to a peripheral lesion; a normal head impulse in this setting is the worrying finding. Nystagmus that changes direction with gaze, or any vertical skew on alternate cover testing, points to a central cause. Any one central sign is enough to treat as possible stroke.
- Normal head impulse with nystagmus at rest: think stroke
- Direction-changing nystagmus on lateral gaze: central
- Skew deviation on cover test: central
- Add a hearing check — new unilateral hearing loss can signal AICA stroke
Why it matters
Misreading the head impulse is one of the commonest ways a posterior circulation stroke is sent home.
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