Objective measurement of HINTS (Head Impulse, Nystagmus, Test of Skew) in peripheral vestibulopathy

Dong-Han Lee; Erich Schneider; Sang-Yeon Lee; Ji-Soo Kim; Ja-Won Koo

doi:10.1016/j.anl.2022.03.003

Objective measurement of HINTS (Head Impulse, Nystagmus, Test of Skew) in peripheral vestibulopathy

Auris Nasus Larynx. 2022 Dec;49(6):938-949. doi: 10.1016/j.anl.2022.03.003. Epub 2022 Mar 23.

Authors

Dong-Han Lee¹, Erich Schneider², Sang-Yeon Lee³, Ji-Soo Kim⁴, Ja-Won Koo⁵

Affiliations

¹ Department of Otorhinolaryngology & Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Otorhinolaryngology-Head and Neck Surgery, Konkuk University Medical Center, Seoul, Republic of Korea.
² Institute of Medical Technology, Brandenburg University of Technology Cottbus - Senftenberg, Germany.
³ Department of Otorhinolaryngology & Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea.
⁴ Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea.
⁵ Department of Otorhinolaryngology & Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea. Electronic address: jwkoo99@snu.ac.kr.

PMID: 35339313
DOI: 10.1016/j.anl.2022.03.003

Abstract

Objective: To evaluate how often the positive sign of HINTS (Head-Impulse, Gaze Evoked Nystagmus, Test of Skew) appears in patients with acute peripheral vestibular lesion, HINTS findings were quantitatively measured and analyzed in patients with peripheral vestibulopathy accompanying spontaneous nystagmus.

Methods: HINTS was evaluated in 14 vertigo patients with spontaneous nystagmus. Horizontal vestibulo-ocular reflex (VOR) gain was measured using the video head impulse test (vHIT). To evaluate gaze-evoked nystagmus (GEN), slow-phase velocities at different points of lateral gaze were measured and plotted, then the slope and its inverse value, the neural integrator time constant, were calculated. Skew deviation was tested using anaglyph filters to simulate the alternate cover test, and the degree and latency of vertical eyeball deviation were measured. The ABCD2 score was calculated to evaluate the risk of stroke.

Results: Among 13 patients of peripheral vestibulopathy, 7 showed positive signs in HINTS (normal vHIT: 5, direction-changing GEN: 0, skew deviation: 3). One patient with a cerebellopontine angle tumor presented with both a peripheral and central pattern and showed positive HINTS findings (presence of direction-changing GEN). The mean VOR gain of patients with abnormal vHIT was 0.58±0.29 and 1.10±0.11 in the affected and contralateral side, respectively, while those in patients with normal vHIT were 1.04±0.21 and 1.13±0.12, respectively. The neural integrator time constant calculated from the mean slope of horizontal slow-phase velocity according to horizontal eye position was 42.9 s. The mean vertical eyeball deviation of patients with positive skew was 2.14±1.18° while uncovering the eye on the affected side, and -1.97±1.59° while uncovering the eye on the unaffected side. The median ABCD2 score of 14 patients was 2 (range, 1-3).

Conclusions: HINTS findings were objectively measured in vertigo patients with spontaneous nystagmus. Although positive findings of HINTS have been recognized as a central sign, 54% (7/13) of cases with peripheral vestibulopathy showed positive HINTS signs. HINTS results should be interpreted carefully considering that a substantial proportion of peripheral vestibulopathy shows a positive HINTS sign.

Keywords: Dizziness; Head impulse test; Nystagmus; Skew deviation; Vertigo.

MeSH terms

Head Impulse Test / methods
Humans
Nystagmus, Pathologic* / diagnosis
Reflex, Vestibulo-Ocular / physiology
Vertigo / diagnosis
Vestibule, Labyrinth*