Can We Detect Central Vertigo on Exam?

Written by Andy Hogan

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HINTS and STANDING exams performed by emergency physicians (EPs) formally trained in both techniques demonstrated very high sensitivity for detecting central causes of vertigo in the ED.

?Why does this matter
Differentiating posterior circulation stroke from peripheral vertigo is challenging, and 10-30% of these strokes are missed in the ED. Studies have shown that EPs frequently misuse or misinterpret important techniques like the HINTS exam when evaluating patients with vertigo. This study suggests EPs, after completing focused training on the HINTS and STANDING exams, can reliably use these tests to rule out central vertigo in many cases (see STANDING Figure and tortured acrostic).

Take a HINT…S exam training to improve rule out of posterior stroke
This single-center study analyzed 300 prospectively enrolled ED patients presenting with vertigo. All underwent HINTS and STANDING exams in the ED as well as an eventual confirmatory brain MRI. HINTS and STANDING exams were administered by study team members with 6 hours of dedicated training on both techniques.

The HINTS exam demonstrated sensitivity of 96.7% for central vertigo, which rose to 97.9% when non-stroke etiologies of central vertigo were excluded. This latter value corresponds to a NPV of 99.4%, suggesting that a patient with overtly peripheral findings on HINTS exam had <1% chance of having a posterior circulation stroke. The STANDING exam, which uses Frenzel glasses to enhance detection of nystagmus but does not test for skew, exhibited lower sensitivity (93.4%) but higher specificity (75%) than the HINTS exam (67.4%).

The single-center nature of this study limits its broad applicability. The findings do, however, suggest that formal training in the HINTS exam can significantly improve an EP’s ability to rule out posterior circulation stroke without MRI or a specialist consult. Adding Frenzel glasses to the ED toolkit may also improve detection of nystagmus and reduce false positive HINTS results.

Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study [published online ahead of print, 2021 Jul 10]. Acad Emerg Med. 2021;10.1111/acem.14337. doi:10.1111/acem.14337

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