Accuracy of the bedside head impulse test in detecting vestibular hypofunction

Jorns-Häderli, M; Straumann, Dominik; Palla, Antonio

doi:10.1136/jnnp.2006.109512

Cited by 159 publications

(149 citation statements)

References 21 publications

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“…There are no data on interrater reliability of HINTS between specialists and EPs, but novice and experienced specialists interpret head impulse test results similarly most of the time. 57 National extrapolations are rough approximations based on best, but limited, available evidence. We did not conduct a formal cost-utility analysis using current data, although our prior analysis suggested implementing the HINTS approach would save lives and prove highly cost-effective.…”

Section: Limitationsmentioning

confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

307

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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Section: Limitationsmentioning

confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

307

351

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“…New video-based equipment that enables registration of the eye response to sudden head impulses mimicking the performance of the scleral search coil (SSC) in a magnetic field installation has recently become available for clinical use [3,4] . With this video head-impulse test (vHIT) system, it is possible to measure the gain of the vestibulo-ocular reflex (VOR) and to register eventual refixation saccades with stimulations (head impulses) that acquire high velocity (>150º/s) and acceleration (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16). This system is good not only for initial evaluation of the patient but also for follow-up, as has been demonstrated in patients with MD with rapid fluctuations in vestibular function [5] .…”

Section: Introductionmentioning

confidence: 99%

The Caloric Test and the Video Head-Impulse Test in Patients with Vertigo

Eza-Nuñez¹,

Fariñas‐Álvarez²,

Pérez-Fernández³

2014

Int Adv Otol

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OBJECTIVE:The caloric test and the video head-impulse test are diagnostic tools that examine the function of the horizontal semicircular canal. There are major differences between the two tests. These are stimulus characteristics, methodology, and function examined. MATERIALS and METHODS:This is a prospective work in 123 patients with different types of vestibular disease seen because of dizziness in which both procedures were performed the same day. First, the spontaneous nystagmus and head-shake nystagmus were measured. The video head-impulse test was carried out, and finally, the caloric test was performed with water at two different temperatures. Both ears were irrigated alternately. Main outcome measures were the canal paresis in the caloric test and gain of vestibulo-ocular reflex, gain asymmetry, and refixation saccades in the vHIT. RESULTS:The caloric test and the vHIT results were fully coincident in 60 patients (48.7%), and the results for both were normal in 36 patients. Discrepancies were found in 3 patients regarding the deficient side, and in 14 patients, an added contralateral (according to the caloric test) abnormal result was obtained. In 46 patients, one of the tests was normal while the other was not, but both were in accordance with the diseased side. The correlation coefficient for canal paresis and gain asymmetry was 0.67, and the agreement was low: κ=0.252. CONCLUSION:The assessment of horizontal semicircular canal function with the vHIT needs to take into consideration not only the gain in VOR but also the existence of refixation saccades. The information from both methods is redundant in some cases but complementary in most, and the existence of discrepancies is very low.

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“…2 Of the 3 tests, the h-HIT is the most technically demanding to perform, and interpretation varies with expertise. 6 Even neuro-otology subspecialists can be deceived when interpreting the h-HIT nonquantitatively because it relies on perception of a fast, corrective eye movement during the test ( Figure 1A, red chevrons) that may sometimes be hidden (covert saccades). 7 An easy-to-use, lightweight, portable, noninvasive videooculography device has been developed that accurately measures the h-HIT vestibulo-ocular reflex (VOR) under controlled, laboratory conditions.…”

mentioning

confidence: 99%

Quantitative Video-Oculography to Help Diagnose Stroke in Acute Vertigo and Dizziness

Newman‐Toker

Tehrani

Mantokoudis

et al. 2013

Stroke

164

167

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Background and Purpose— Strokes can be distinguished from benign peripheral causes of acute vestibular syndrome using bedside oculomotor tests (head impulse test, nystagmus, test-of-skew). Using head impulse test, nystagmus, test-of-skew is more sensitive and less costly than early magnetic resonance imaging for stroke diagnosis in acute vestibular syndrome but requires expertise not routinely available in emergency departments. We sought to begin standardizing the head impulse test, nystagmus, test-of-skew diagnostic approach for eventual emergency department use through the novel application of a portable video-oculography device measuring vestibular physiology in real time. This approach is conceptually similar to ECG to diagnose acute cardiac ischemia. Methods— Proof-of-concept study (August 2011 to June 2012). We recruited adult emergency department patients with acute vestibular syndrome defined as new, persistent vertigo/dizziness, nystagmus, and (1) nausea/vomiting, (2) head motion intolerance, or (3) new gait unsteadiness. We recorded eye movements, including quantitative horizontal head impulse testing of vestibulo-ocular-reflex function. Two masked vestibular experts rated vestibular findings, which were compared with final radiographic gold-standard diagnoses. Masked neuroimaging raters determined stroke or no stroke using magnetic resonance imaging of the brain with diffusion-weighted imaging obtained 48 hours to 7 days after symptom onset. Results— We enrolled 12 consecutive patients who underwent confirmatory magnetic resonance imaging. Mean age was 61 years (range 30–73), and 10 were men. Expert-rated video-oculography–based head impulse test, nystagmus, test-of-skew examination was 100% accurate (6 strokes, 6 peripheral vestibular). Conclusions— Device-based physiological diagnosis of vertebrobasilar stroke in acute vestibular syndrome should soon be possible. If confirmed in a larger sample, this bedside eye ECG approach could eventually help fulfill a critical need for timely, accurate, efficient diagnosis in emergency department patients with vertigo or dizziness who are at high risk for stroke.

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Accuracy of the bedside head impulse test in detecting vestibular hypofunction

Abstract: When qHIT is used as a reference, bHIT sensitivity is adequate and therefore clinically useful in the hands of both neuro-otological experts and non-experts. We advise performing quantitative head impulse testing with search coils or high speed video methods when bHIT is not conclusive.

Cited by 159 publications

References 21 publications

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

The Caloric Test and the Video Head-Impulse Test in Patients with Vertigo

Quantitative Video-Oculography to Help Diagnose Stroke in Acute Vertigo and Dizziness

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