Real-world use and diagnostic performance of the head impulse, nystagmus, and test of skew examination in acute vestibular syndrome: an Australian tertiary hospital study.

BACKGROUND The HINTS (head impulse, nystagmus, and test of skew) examination can surpass early magnetic resonance imaging (MRI) in detecting central causes of acute vestibular syndrome (AVS) when performed by neurologists, but its accuracy in routine hospital practice by non-neurologists is uncertain.

AIMS To evaluate the utilisation, documentation, diagnostic accuracy and clinical influence of HINTS in AVS cases at a tertiary Australian hospital and whether combining HINTS with the ABCD2 (age, blood pressure, clinical features, duration, diabetes (clinical risk score)) score improves diagnosis.

METHODS We retrospectively reviewed adult AVS presentations to the Gold Coast University Hospital's emergency department from January 2021 to July 2024. Data included HINTS performance rates, documentation completeness, clinician specialty/seniority and impact on neuroimaging decisions. Diagnostic metrics were compared with MRI, and we assessed whether combining 'central' HINTS with an ABCD2 score ≥4 improved test characteristics.

RESULTS Of 322 patients, fully performed HINTS examinations were completed in 42% of emergency department, 40% of neurology, 18% of general medicine and 93% of physiotherapy encounters. Documentation completeness ranged from 30% (general medicine) to 89% (physiotherapy). Sensitivity for central causes was low (21.4% in emergency, 58.8% in physiotherapy), and inter-rater agreement was poor (κ = 0.10). HINTS rarely altered MRI ordering, except in physiotherapy. Combining a central HINTS with an ABCD2 score ≥4 improved specificity but reduced sensitivity.

CONCLUSIONS HINTS was under-utilised and inconsistently interpreted and demonstrated lower accuracy in this study compared with previous studies involving neurology specialists. Improved training and standardisation of documentation are needed to optimise AVS diagnosis and care.