Step 1: Determine whether patient is having Vertigo (spinning sensation) or Pre-Syncopal sensation (about to faint/fall) as the differential and workup will be different
Vertigo: is it Central vs. Peripheral?
Remember that ALL vertigo gets worse with movement!
-Vestibular neuritis (remember that labrynthitis refers to involvement of the inner ear while neuritis refers to involvement of the vestibular nerve)
-Ramsay Hunt Syndrome
How can you tell the difference between Central and Peripheral Vertigo?
If someone has ongoing vertigo and nystagmus, The HiNTs exam can be used to differentiate posterior circulation syndrome (brainstem or cerebellar stroke) vs. vestibular neuritis
1)Head impulse testing-“normal” test is POSITIVE meaning no saccade/correction on head rotation
2)Nystagmus-Nystagmus that changes direction or pure vertical/torsional nytagmus
3)Test of skew –Covering and uncovering each eye and uncovered eye demonstrates quick vertical gaze corrections
1/3 POSITIVE tests indicates patient may have a posterior circulation stroke.
Check out this EMcrit video that has a blog and video on how to do the HiNTs exam!
See original study here in Stroke Journal-on this study, the maneuver was 100 % sensitive and 96 % specific for posterior circulation stroke