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HINTS Central Pattern – Dangerous Signs — SCE Neurology MCQ

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ModerateCerebrovascular DiseaseHINTS Central Pattern – Dangerous SignsSCE Neurology

A 50-year-old woman with MS develops acute onset of spinning vertigo, nausea, and vomiting. Her head impulse test is NORMAL (no corrective saccade). Her nystagmus is direction-changing (beats right on right gaze, left on left gaze). Skew deviation is present. What does the HINTS examination suggest?

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Correct answer: B — CENTRAL cause (brainstem/cerebellar stroke or MS plaque) — a dangerous HINTS pattern: normal head impulse test + direction-changing nystagmus + skew deviation all point to a central lesion

HINTS central pattern: (1) NORMAL head impulse test (the brainstem vestibular pathways are intact, so the VOR reflex works — unlike peripheral lesions where the reflex fails), (2) direction-changing nystagmus (central nystagmus often changes direction with gaze), (3) skew deviation (vertical misalignment from otolithic pathway disruption — a central sign). Any ONE of these three findings is sufficient to suspect a central cause. HINTS is >99% sensitive for detecting posterior circulation stroke when all three criteria are applied correctly. A: All three criteria point to central. C: BPPV is positional. D: Ménière has hearing loss. E: Labyrinthitis has positive HIT.

Reference: Kattah et al. HINTS (2009); ABN/ACNR Vertigo Guidelines