The head impulse, nystagmus, test of skew examination has been in use since 2009 for separating peripheral vestibular disease from posterior circulation stroke. This review argues that the persistent problem is not the test but the patients it is applied to.
Two conditions define its territory. The dizziness must be continuous, not episodic. And there must be spontaneous nystagmus at rest. A patient with intermittent positional vertigo and no nystagmus is not a HINTS patient, and performing it anyway produces a result that reads as reassuring while meaning nothing. The second error is sequence: central features - new headache, diplopia, dysarthria, limb ataxia, a focal deficit - are screened for first, and their presence ends the question rather than prompting a HINTS. The authors note that the third GRACE emergency guidance may itself have introduced ambiguity on these points.
A normal HINTS in the wrong patient is the most dangerous result in the whole examination, because it carries the authority of a specific test. In settings where the alternative to a bedside decision is an MRI that will not happen tonight, getting the indication right is the whole value of the tool.
- Perform HINTS only when dizziness is continuous and nystagmus is present at rest.
- Screen for central features first; their presence ends the question rather than starting a HINTS.
- A reassuring HINTS in a patient without nystagmus should not be recorded as reassuring.
- Episodic positional vertigo is a Dix-Hallpike problem, not a HINTS problem.
- Document which of the three components were done and what each showed, not just the conclusion.
Why it matters
A normal HINTS in the wrong patient carries the authority of a specific test and is the commonest way a posterior circulation stroke gets sent home.
Don't overread it
A narrative review of practice, not new diagnostic accuracy data - it clarifies indication rather than revising the test's performance.
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