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    Patent Pending

    HINTS for Stroke in Acute Vestibular Syndrome

    Identifies potential stroke in patients with acute vestibular syndrome (AVS).


    Proper administration of the test itself is critical to using this calculator. See a video from the authors here.

    When to Use
    Why Use

    Only use in patients with continuous vertigo. Do not use in patients with episodic vertigo (e.g. benign paroxysmal positional vertigo) or whose dizziness has resolved by the time of assessment.

    • Requires some specialized experience to perform, and sensitivity is reduced in non-neuro-ophthalmologists (Kerber 2015). Ruling out stroke in patients with a moderate or high pre-test probability may not be possible by non-specialists.

    • Acute (<24-48 hours) MRI has lower sensitivity for posterior fossa ischemia than HINTS, assuming scoring by a specialist (Kattah 2009). In non-expert hands, consideration of the patient’s overall vascular risk (e.g. ABCD² Score) improves the sensitivity of the assessment. Delayed or repeat MRI (>48 hours) may be useful in ambiguous cases.

    • Ischemia in the territory of the anterior inferior cerebellar artery can mimic a peripheral etiology and should be kept in the differential when the HINTS localizes to the periphery but the patient has vascular risk factors, experiences sudden onset of symptoms, and/or has associated ipsilateral hearing loss.

    • AVS is a common presentation to EDs, outpatient clinics, and inpatient services. Differentiation between central and peripheral etiologies is important in narrowing the differential diagnosis and facilitate emergent therapies.

    • Acute MRI (<24-48 hours) may initially be falsely negative due to lower resolution in the posterior fossa in this time window, and so a “normal” MRI in this population cannot be relied upon to provide complete reassurance.

    Direction-fixed horizontal nystagmus
    Direction-changing horizontal/untestable nystagmus
    Absent skew deviation
    Present/untestable skew deviation


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    Creator Insights
    Dr. David E. Newman-Toker

    About the Creator

    David E. Newman-Toker, MD, PhD, is the director of the Division of Neuro-Visual and Vestibular Disorders at Johns Hopkins Medicine in Baltimore, MD. He is also a professor of neurology at Johns Hopkins University School of Medicine. Dr. Newman-Toker’s primary research is focused on diagnosis of stroke in patients presenting with acute, severe vertigo or dizziness.

    To view Dr. David E. Newman-Toker's publications, visit PubMed

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    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Content Contributors
    • Antony Winkel, MBBS, FRACP
    About the Creator
    Dr. David E. Newman-Toker
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    Content Contributors
    • Antony Winkel, MBBS, FRACP