The head impulse, nystagmus and test of skew examination was validated in patients with continuous vertigo and spontaneous nystagmus — the acute vestibular syndrome. In that group it separates peripheral from central causes well when done by trained examiners.
Without spontaneous nystagmus, a normal head impulse test cannot be read as reassuring. In such patients the key bedside test is whether they can sit and stand unaided and walk. Severe truncal or gait ataxia in an acutely dizzy patient is a central sign until proved otherwise.
- Look for spontaneous nystagmus before applying HINTS; without it, the test does not apply.
- Ask every acutely dizzy patient to sit unsupported, stand and walk.
- Treat inability to stand or walk unaided as a central sign until imaging says otherwise.
- Remember a normal CT does not exclude posterior fossa stroke; MRI with diffusion is needed.
Why it matters
A normal head impulse in a patient without nystagmus is commonly misread as reassurance.
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