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Objective measurement of HINTS (Head Impulse, Nystagmus, Test of Skew) in peripheral vestibulopathy

  • Dong-Han Lee
    Affiliations
    Department of Otorhinolaryngology & Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea

    Department of Otorhinolaryngology-Head and Neck Surgery, Konkuk University Medical Center, Seoul, Republic of Korea
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  • Erich Schneider
    Affiliations
    Institute of Medical Technology, Brandenburg University of Technology Cottbus - Senftenberg, Germany
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  • Sang-Yeon Lee
    Affiliations
    Department of Otorhinolaryngology & Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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  • Ji-Soo Kim
    Affiliations
    Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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  • Ja-Won Koo
    Correspondence
    Corresponding at: Department of Otorhinolaryngology & Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea. Gumi-ro 173-Beon-gil 82, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea.
    Affiliations
    Department of Otorhinolaryngology & Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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Published:March 23, 2022DOI:https://doi.org/10.1016/j.anl.2022.03.003

      ABSTRACT

      Objective

      To evaluate how often the positive sign of HINTS (Head-Impulse, Gaze Evoked Nystagmus, Test of Skew) appears in patients with acute peripheral vestibular lesion, HINTS findings were quantitatively measured and analyzed in patients with peripheral vestibulopathy accompanying spontaneous nystagmus.

      Methods

      HINTS was evaluated in 14 vertigo patients with spontaneous nystagmus. Horizontal vestibulo-ocular reflex (VOR) gain was measured using the video head impulse test (vHIT). To evaluate gaze-evoked nystagmus (GEN), slow-phase velocities at different points of lateral gaze were measured and plotted, then the slope and its inverse value, the neural integrator time constant, were calculated. Skew deviation was tested using anaglyph filters to simulate the alternate cover test, and the degree and latency of vertical eyeball deviation were measured. The ABCD2 score was calculated to evaluate the risk of stroke.

      Results

      Among 13 patients of peripheral vestibulopathy, 7 showed positive signs in HINTS (normal vHIT: 5, direction-changing GEN: 0, skew deviation: 3). One patient with a cerebellopontine angle tumor presented with both a peripheral and central pattern and showed positive HINTS findings (presence of direction-changing GEN). The mean VOR gain of patients with abnormal vHIT was 0.58±0.29 and 1.10±0.11 in the affected and contralateral side, respectively, while those in patients with normal vHIT were 1.04±0.21 and 1.13±0.12, respectively. The neural integrator time constant calculated from the mean slope of horizontal slow-phase velocity according to horizontal eye position was 42.9 s. The mean vertical eyeball deviation of patients with positive skew was 2.14±1.18° while uncovering the eye on the affected side, and -1.97±1.59° while uncovering the eye on the unaffected side. The median ABCD2 score of 14 patients was 2 (range, 1-3).

      Conclusions

      HINTS findings were objectively measured in vertigo patients with spontaneous nystagmus. Although positive findings of HINTS have been recognized as a central sign, 54% (7/13) of cases with peripheral vestibulopathy showed positive HINTS signs. HINTS results should be interpreted carefully considering that a substantial proportion of peripheral vestibulopathy shows a positive HINTS sign.

      Keywords

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      References

        • Hotson JR
        • Baloh RW.
        Acute vestibular syndrome.
        N Engl J Med. 1998; 339: 680-685
        • Edlow JA
        • Newman-Toker DE
        • Savitz SI.
        Diagnosis and initial management of cerebellar infarction.
        Lancet Neurol. 2008; 7: 951-964
        • Cnyrim CD
        • Newman-Toker D
        • Karch C
        • Brandt T
        • Strupp M.
        Bedside differentiation of vestibular neuritis from central "vestibular pseudoneuritis".
        J Neurol Neurosurg Psychiatry. 2008; 79: 458-460
        • Kattah JC
        • Talkad AV
        • Wang DZ
        • Hsieh YH
        • Newman-Toker DE.
        HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
        Stroke. 2009; 40: 3504-3510
        • Yang C
        • Lee J
        • Kang B
        • Lee H
        • Yoo M
        • Park H.
        Quantitative analysis of gains and catch-up saccades of video-head-impulse testing by age in normal subjects.
        Clin Otolaryngol. 2016; 41: 532-538
        • Cleworth TW
        • Carpenter MG
        • Honegger F
        • Allum JHJ.
        Differences in head impulse test results due to analysis techniques.
        J Vestib Res. 2017; 27: 163-172
        • Bertolini G
        • Tarnutzer AA
        • Olasagasti I
        • Khojasteh E
        • Weber KP
        • Bockisch CJ
        • et al.
        Gaze holding in healthy subjects.
        PLoS One. 2013; 8: e61389
        • Romano F
        • Tarnutzer AA
        • Straumann D
        • Ramat S
        • Bertolini G.
        Gaze-evoked nystagmus induced by alcohol intoxication.
        J Physiol. 2017; 595: 2161-2173
        • Tarnutzer AA
        • Weber KP
        • Schuknecht B
        • Straumann D
        • Marti S
        • Bertolini G.
        Gaze holding deficits discriminate early from late onset cerebellar degeneration.
        J Neurol. 2015; 262: 1837-1849
        • Van Esch B
        • Nobel-Hoff G
        • Van Benthem P
        • Van Der Zaag-Loonen H
        • Bruintjes TD.
        Determining vestibular hypofunction: start with the video-head impulse test.
        Eur Archiv Oto-Rhino-Laryngology. 2016; 273: 3733-3739
        • Weber KP
        • Aw ST
        • Todd MJ
        • McGarvie LA
        • Curthoys IS
        • Halmagyi GM.
        Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades.
        Neurology. 2008; 70: 454-463
        • Elzenman M
        • Cheng P
        • Sharpe JA
        • Frecker RC.
        End-point nystagmus and ocular drift: an experimental and theoretical study.
        Vision Res. 1990; 30: 863-877
        • Whyte CA
        • Petrock AM
        • Rosenberg M.
        Occurrence of physiologic gaze-evoked nystagmus at small angles of gaze.
        Invest Ophthalmol Vis Sci. 2010; 51: 2476-2478
        • Johnston SC
        • Rothwell PM
        • Nguyen-Huynh MN
        • Giles MF
        • Elkins JS
        • Bernstein AL
        • et al.
        Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.
        Lancet North Am Ed. 2007; 369: 283-292
        • Halmagyi GM
        Curthoys IS. A clinical sign of canal paresis.
        Arch Neurol. 1988; 45: 737-739
        • Bartl K
        • Lehnen N
        • Kohlbecher S
        • Schneider E.
        Head impulse testing using video-oculography.
        Ann NY Acad Sci. 2009; 1164: 331-333
        • MacDougall HG
        • Weber KP
        • McGarvie LA
        • Halmagyi GM
        • Curthoys IS.
        The video head impulse test: diagnostic accuracy in peripheral vestibulopathy.
        Neurology. 2009; 73: 1134-1141
        • Ulmer E
        • Chays A.
        [Curthoys and Halmagyi Head Impulse test: an analytical device].
        Ann Otolaryngol Chir Cervicofac. 2005; 122: 84-90
        • MacDougall HG
        • McGarvie LA
        • Halmagyi GM
        • Rogers SJ
        • Manzari L
        • Burgess AM
        • et al.
        A new saccadic indicator of peripheral vestibular function based on the video head impulse test.
        Neurology. 2016; 87: 410-418
        • Lee H
        • Cho Y-W.
        A case of isolated nodulus infarction presenting as a vestibular neuritis.
        J Neurol Sci. 2004; 221: 117-119
        • Lee H
        • Sohn S-I
        • Cho Y-W
        • Lee S-R
        • Ahn B-H
        • Park B-R
        • et al.
        Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns.
        Neurology. 2006; 67: 1178-1183
        • Kattah JC.
        Use of HINTS in the acute vestibular syndrome. An Overview.
        Stroke Vasc Neurol. 2018; 3: 190-196
        • Newman-Toker DE
        • Kattah JC
        • Alvernia JE
        • Wang DZ.
        Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis.
        Neurology. 2008; 70: 2378-2385
        • Weber K
        • Aw S
        • Todd M
        • McGarvie L
        • Curthoys I
        • Halmagyi G.
        Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades.
        Neurology. 2008; 70: 454-463
        • Kim TS
        • Lim HW
        • Yang CJ
        • Kim YH
        • Choi WR
        • Kim YR
        • et al.
        Changes of video head impulse test results in lateral semicircular canal plane by different peak head velocities in patients with vestibular neuritis.
        Acta Otolaryngol. 2018; 138: 785-789
        • Buttner U
        • Grundei T.
        Gaze-evoked nystagmus and smooth pursuit deficits: their relationship studied in 52 patients.
        J Neurol. 1995; 242: 384-389
        • Yetiser S
        • Ince D
        • Yetiser B.
        Optokinetic analysis in patients with spontaneous horizontal gaze-evoked nystagmus without radiological neuropathology.
        Ear Nose Throat J. 2019; 98: 420-424
        • Becker W
        • Klein HM.
        Accuracy of saccadic eye movements and maintenance of eccentric eye positions in the dark.
        Vision Res. 1973; 13: 1021-1034
        • Brodsky MC
        • Donahue SP
        • Vaphiades M
        • Brandt T.
        Skew deviation revisited.
        Surv Ophthalmol. 2006; 51: 105-128
        • Klaehn LD
        • Hatt SR
        • Leske DA
        • Holmes JM.
        Role of a standardized prism under cover test in the assessment of dissociated vertical deviation.
        Strabismus. 2018; 26: 1-5
        • Park HJ
        • Migliaccio AA
        • Della Santina CC
        • Minor LB
        • Carey JP
        Search-coil head-thrust and caloric tests in Meniere's disease.
        Acta Otolaryngol. 2005; 125: 852-857
        • Tsuji K
        • Velázquez-Villaseñor L
        • Rauch SD
        • Glynn RJ
        • Wall 3rd, C
        • Merchant SN.
        Temporal bone studies of the human peripheral vestibular system. Meniere's disease.
        Ann Otol Rhinol Laryngol Suppl. 2000; 181: 26-31
        • Lee SU
        • Kim HJ
        • Choi JY
        • Koo JW
        • Kim JS
        Evolution of caloric responses during and between the attacks of Meniere's disease.
        J Neurol. 2021; 268: 2913-2921
        • McGarvie LA
        • Curthoys IS
        • MacDougall HG
        • Halmagyi GM.
        What does the head impulse test versus caloric dissociation reveal about vestibular dysfunction in Ménière's disease?.
        Ann N Y Acad Sci. 2015; 1343: 58-62
        • McGarvie LA
        • Curthoys IS
        • MacDougall HG
        • Halmagyi GM.
        What does the dissociation between the results of video head impulse versus caloric testing reveal about the vestibular dysfunction in Ménière's disease?.
        Acta Otolaryngol. 2015; 135: 859-865
        • Asprella Libonati G.
        Diagnostic and treatment strategy of lateral semicircular canal canalolithiasis.
        Acta Otorhinolaryngol Ital. 2005; 25: 277-283
        • Lee SU
        • Kim HJ
        • Kim JS.
        Pseudo-spontaneous and head-shaking nystagmus in horizontal canal benign paroxysmal positional vertigo.
        Otol Neurotol. 2014; 35: 495-500
        • Newman-Toker DE
        • Curthoys IS
        • Halmagyi GM.
        Diagnosing stroke in acute vertigo: The HINTS family of eye movement tests and the future of the "Eye ECG".
        Semin Neurol. 2015; 35: 506-521
        • Safran AB
        • Vibert D
        • Issoua D
        • Hausler R.
        Skew deviation after vestibular neuritis.
        Am J Ophthalmol. 1994; 118: 238-245
        • Halmagyi GM
        • Weber KP
        • Curthoys IS.
        Vestibular function after acute vestibular neuritis.
        Restor Neurol Neurosci. 2010; 28: 37-46