Meta-Analysis of the Use of Head Impulse Test and Head Impulse Test with Direction Changing Nystagmus and Test of Skew Deviation in the Diagnosis of Peripheral Vertigo and Stroke

Abstract

<b><i>Introduction:</i></b> The head impulse test (HIT) and HIT combined with direction-changing Nystagmus-Test of Skew deviation (HINTS) have been proposed as bedside tests to differentiate between peripheral and central causes of vertigo in the emergency department (ED). We conducted a meta-analysis of the HIT and HINTS tests to diagnose peripheral vertigo (PV) and central vertigo. <b><i>Methods:</i></b> Pubmed, Google Scholar, EmBase, and articles references published in English up to July 2021 were searched for keywords “vertigo” or “acute vestibular syndrome” or “dizziness” and “head impulse” and “stroke.” The bivariate method for meta-analysis was used to calculate positive (PLR) and negative likelihood ratios (NLR) and summary receiver operating characteristics area under the curve (AUC). <b><i>Results:</i></b> A total of 11 studies were included analysing both HIT (8 studies, <i>N</i> = 417) and HINTS (6 studies, <i>N</i> = 405). HIT and HINTS were performed within 24 h in 4 of 11 studies. PLR and NLR for HIT in PV was 4.85 (95% CI: 2.83–8.08) and 0.19 (95% CI: 0.12–0.29, <i>I</i><sup>2</sup> 63.25%), respectively. The AUC for HIT the diagnosis of PV and stroke was 0.90 and 0.92, respectively. PLR and NLR for a negative HIT in stroke was 5.85 (95% CI: 3.07–10.6) and 0.17 (95% CI: 0.08–0.30), respectively. PLR and NLR for peripheral HINTS pattern for PV was 17.3 (95% CI: 8.38–32.1) and 0.15 (95% CI: 0.07–0.26), respectively. PLR and NLR for central HINTS pattern for stroke: 5.61 (95% CI: 4.19–7.7) and 0.06 (95% CI: 0.03–0.12). In all included studies, HIT and HINTS exams were administered by neurology residents or neurology specialists with additional neuro-otology or neuro-ophthalmology subspeciality experience, and two studies included ED physicians. Raters reported high degree of bias and high concern regarding applicability in most domains of the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Meta-regression did not demonstrate a statistically significant effect of publication year, time to test, and type of assessor on sensitivity or false positive rate. <b><i>Conclusion:</i></b> The HIT and HINTS exams appear to be moderately good discriminators of central and PV. However, in most papers, the tests were administered by neurologists and were evaluated beyond 24 h, which may limit utility in the ED setting.

Training on HINTS exam: Results from a quasi - experimental study in Medicine Students

“…HINTS exam proved to be a useful bedside tool but needs further evaluation in Emergency Departments and Outpatients Settings by practitioners, who are the rst line responders performing this exam (7).…”

“…HINTS exam training may present some challenges. First, an established timeline for physicians and nonphysicians may take time to gain an accurate and deep understanding of it (7). Second, emergency doctors and trainees may be uncomfortable or unfamiliar with the correct performance of HINTS and its interpretation (8).…”

Video head impulse test in stroke: a review of published studies

“…HINTS exam has demonstrated high sensitivity in detecting PCS (7,8,18,37). However, vHIT is shown to be more specific in detecting PCS (16,38).…”

“…In this test, patients lie supine at 30 degrees, and warm and coldwater solutions are irrigated into the affected ear within 25 to 30 s, with resulting nystagmus observed (37,45) (6). In cases of normal vHIT, it is advisable to proceed with caloric testing to rule out peripheral vertigo.…”

“…Contraversive SVH deviation, indicating lesions rostral to the pons, is a precise yet insensitive indicator of PCS. SVH is more likely to produce abnormal results in either VN or PCS, making it a poor discriminatory test to distinguish between the two (19,37).…”