Excellent video. Primary care doctor in UK. Is a struggle to find any clear guidance on no nystagmus with persistent dizziness now i understand why. So that was really useful alongside when not to use HINTS and why. Thank you!
Hi Peter ! As always clearly and thoroughly explained with logical arguments! Where do I sign the petition for getting you , Drs Edlow, Newman-Toker and Kattah in the same room and discuss the 2% that you guys disagree about !? Small comments / questions (it’s a bit long - sorry. And I have no expectation of getting an answer) - 1) To HINTS plus or not : To my knowledge there’s no studies (and probably won’t be any) of the + / hearing loss part in HINTS+. Let’s say you have a patient testing negative central features , and the HINTS test suggest vestibular neuritis but the patient also has hearing loss (ruling in for HINTS+). I guess there’s no safe way other than an MRI to differentiate the AICA stroke from Labyrinthitis (in my experience they tend to have elevated inflammation makers as well , but probably that is not a specific enough finding to rule out the AICA)? - 2) the “AVS+nystagmus”-like presentation in some BPPV patients: I think some of the confusion with application of HINTS lies in not knowing the data . But I think some of it may be as simple as interpreting what the patient is saying . “Constant dizzyness” is something I hear from some monosymptomatic dizzy patients with a history suggesting BPPV (even though it may be 10-20% of max dizzyness for the patient as opposed to the true “dizzy at baseline” patient with AVS who is maybe at 90-100% of max dizzyness when lying still). Now some of these BPPV patients may have some residual nystagmus if you are not careful in your instructions to them to not move their head for a couple of minutes (especially if they have cupolithiasis and not canalithiasis). So in my experience (which of course may be wrong) some dizzy patients with BPPV will have an “AVS + nystagmus”-like presentation. And I suggest in these cases to my colleagues that if the history and exam in all other aspects suggest BPPV, then I’d try to do the dix hallpike/ supine head roll to see if you get a clearly positive test. - 3) The logistics: Do you have a video where you “real time” do the entire thing (how you ask the questions , in what order you do the exams and how the logistics look like)? I ask , because I feel like the devils with the reason why people for instance are not screening for neuro findings is because they don’t have a clear role model / pattern to follow. It’s not uncommonly difficult to do a thorough exam on the patients with dizzyness because of the nausea and vomiting - especially when you are within the window of thrombolysis and the clock is ticking. As I’ve detailed in my videos on dizzyness m.ruclips.net/video/1dZEAK062Iw/видео.html 26:00, we usually quickly screen for central features (and medical mimicks such as arythmias) + put in line and give ondansetrone and IV fluids -> place a hand on the head of the patient and take the history, making very sure they don’t move to the head for 2-5 minutes -> checking for spontaneous / gaze evoked nystagmus at around 30 degrees eye shift from midline (often helped by Frenzel)-> if nystagmus we do HINTS (unless the patient has a very BPPV like history and maybe slight but not obvious spontaneous nystagmus, then I may do the BPPV provocation manoeuvres occasionally as stated above, but if not clearly positive , then go to HINTS) , If no nystagmus we do BPPV tests -> if no nystagmus and no signs of BPPV only then I’ll get them sitting and on their feet (by now hopefully the drugs have kicked in so this is possible without too much vomiting) and see that they are not truncal ataxic (like you showed clearly in your video examples - can they walk unassisted or not). If their gate is worse than normal and I cannot find any other reason for it , it’s an Acute Instability Syndrome until proven otherwise and they’ll be admitted . Otherwise they’ll go home - 4) Exclusion criterias for HINTS and false positive AIS patients: The patients that are NOT too good walkers at baseline (frail / elderly etc ) or patients who are drunk , would probably be false positive on the approach we advocate for because of their baseline nystagmus and / or gate instability and perhaps in these patients the tests could be used by a case by case basis , but one should be careful of ruling out central causes by bedside manoeuvres alone - 5) HINTS with enucleated eyes with re-attached muscles to the prosthetics: we came across a patient with monosymptomatic constant dizzyness , but with bilateral eye enucleation and the gait was per usual? We went for an MRI on that patient that was normal , but curious if you had done it differently All the best Peter
Thank you Peter! Practicing clinicians sometimes have so many conflicting pieces of information in our head that beating the information into us is needed to shake the bad information loose. I'll find something other than the HINTS exam to do if a patient does not have persistent dizziness and nystagmus at rest. Like getting a cup of coffee...to give me more time to think.
@@PeterJohns it’s already better, thank you 🙂 I have two more questions, If you don’t mind🙂 I am physical terapist and I do Manual therapy for neck, and sometimes vertigo wanish after I fix a neck! Do you think that vertigo with nistagmus has ever cervikal spine origin? 2. Do you consider By term “spontaneous nistagmus”, when someone is sitting or laying down( straight head or rotated), and watching complitly left or right, and we see miled nistagmus? Thank you Doctor Johns.
@@vinkosusac1130 Cervical vertigo is a controversial topic, and I don't see those patients in the ED, or at least I don't recognize them as such, so I don't have much to say about it. 2. Spontaneous nystagmus is nystagmus when the patient is upright at rest and looking straight ahead. I now have started using the term "nystagmus at rest" which means looking straight ahead or looking 30 degrees left and right without fixation. If you lie someone down or turn their head, this is positional testing, and if typical nystagmus of BPPV is seen in either the Dix-Hallpike test or supine roll test, and typical story is there, and no other neuro signs or symptoms, then the diagnosis of BPPV is made.
Excellent videos. My name is Yafit and I am a physical therapist from Israel. I mainly treat people who suffer from acute and chronic dizziness. Always enjoy learning from your videos! Thank you very much - I would be happy to host you in Israel (on calmer days :)
Thanks for your videos. I would like to suggest that the HIT is useful to do on a patient without gaze nystagmus to assess for unilateral hypofunction. This is not in context of the ED environment where one might be ruling in or out life-threatening etiology, but is helpful in a physical therapy environment to create an exercise program to strengthen the overall system and decrease falls risk. (Herdman, 2011)
Absolutely! The HIT used in isolation, go ahead and use it any time you feel like it. But if are using it in the context of one part of the 3 part HINTS exam, and you're using it on patients who are newly dizzy and have no nystagmus at rest, many false positive will occur.
Thank you. This is the best information on HINTS I have ever found. Amazing. What are your thoughts on other dx of continuous/constant vertigo e.g. PPPD, mal de debarquement etc. Are HINTS useful in these cases? They frequently do not have spontaneous nystagmus, so I guess I already know what you'd say :D
Unless acute vestibular neuritis is part of the differential, using all 3 components of HINTS is not useful. And acute VN shouldn't be a concern in possible PPPD or mal de debarquement syndrome.
@peter Hi Dr Peter , Your videos are really informative and have been of real help for me.. So firstly thank you . Wanted to know, about pediatric BPPV.. I had a 11 yr old boy, with symptoms of rotatory giddiness, 2 episodes over a span of 1 month,. triggered by lying on the bed, no h/o headaches... On dix hallpike , he experienced giddiness on right side.. but there was no nystagmus . Do i treat it as BPPV.... ? Or.. is there something else that need to consider ..
Thank you for this in-depth information. Question…Why was the Romberg done in the 2nd pt? I am thinking that the examiner is testing for balance, but romberg isn’t a cerebellar test…was it done as a vestibular evaluation ….what was the yield in this scenario?
It had no value in the evaluation of this man. You are right that it isn't a cerebellar test. In dizziness people tend to fall over when asked to stand with feet together and eyes open or closed when the dizziness is severe. If you spin yourself around 10 times quickly, you will have much difficult standing with your feet together. Some people are under the impression it has value in determining a central cause over a peripheral cause. I kind of showed this one to point out that it doesn't really help.
Hi Dr. Peter, I am a GP from Beijing, China. Most Chinese doctors cannot watch your fantastic vertigo videos because of network limitations and language barriers. Can I forward your videos to one of the Chinese video websites (bilibili) and put the Chinese subtitle? Thank you, Peter!!!
Does the nystagmus at rest ( while looking straight ahead) and the nystagmus only on gaze deviation either left or right carry the same significance while subjecting them to HINTS examination? Thank you very much for the educative video.
Hi Dr. Johns, I'm a novice medical student, so please forgive me for the very basic question, but I'm wondering how we should interpret gaze-evoked nystagmus (similar to what you mention at around 29 minute mark of the video) in a patient with continuous vertigo, but no spontaneous nystagmus (I.e. when at rest looking straight ahead). Should we also not do a HINTS exam on these patients? Based on the phrasing that we should only be doing HINTS exams on pts with acute vestibular syndrome and spontaneous nystagmus, my assumption is that the answer is NO, but just want to clarify. Thank you.
I consider "nystagmus at rest" to be any nystagmus that is not brought on by positional changes of the head, as in during a Dix-Hallpike test. So "nystagmus at rest" would include nystagmus that is seen when the patient is looking straight ahead (spontaneous nystagmus) and also nystagmus that is only seen when the patient is asked to look left or right 30 degrees. And it would be completely appropriate to perform the HINTS exam in any patient with new onset persistent vertigo and nystagmus at rest. Hope this clear it up.
@@PeterJohns thank you, sir! I’ve been watching your videos and have found them incredibly helpful. Do you have any recommendations for resources or even some of your other videos that talk about how the other less common causes of vertigo should fit into our diagnostic framework? For example, the tintinalli’s algorithm ends by saying “consider other causes” if the Dix-Hallpike maneuver is negative or abnormal. I mostly am finding some confusion as to where questions on history like recent ototoxic medication use (such as gentamicin) or recent head trauma (causing things like post-concussion syndrome or perilymphatic fistula) should fit in the diagnostic framework (should these things be considered after ruling out scary stuff on the Acute vestibular syndrome side of the algorithm or on the episodic vestibular syndrome side). Sorry for the long winded comment, but I greatly appreciate your time and insight!
@@maxgiesken9488 I specifically don't make videos about less common causes of vertigo. This is because most clinicians who haven't received some kind of vertigo training, beyond medical school or residency can't diagnose their way out of a paper bag when it comes to dizziness! Have you read the article by Lessing "Teaching more about less: Preparing clincians for practice". It explains why i do what I do. I can send you the article, it's very short. Glad you have found my videos helpful. It's people like you, learning about vertigo at an early stage in your career, who are the hope for the future. Gentamicin ototoxicity would likely produce bilateral abnormal HIT. Recent trauma can produce BPPV (multiple canals can be affected!). Post concussion syndrome is a diagnosis of exclusion, and by history. Third window problems, like perilymphatic fistula are quite rare. Here is an article if you are interested in that. www.ncbi.nlm.nih.gov/pmc/articles/PMC7963676/#:~:text=Third%20window%20abnormalities%20are%20defects,air%2Dbone%20gap%20by%20audiometry. I sense you will become a vertigo champion!
Hi Peter! So, to be clear, we SHOULD do the HINTS exam only if there is nystagmus at rest OR nystagmus EVOKED by gaze? Or do we only do it if there is nystagmus AT REST?
I consider nystagmus at rest to be any nystagmus that is not brought on by positional changes of the head, as in BPPV. So that would include nystagmus that is brought on by looking left or right 30 degrees with fixation removed.
Hello, a question please; Can a patient have a positive head impulse test (With catch-up saccades) , although they present with no nystagmus at rest? If the answer is yes - wouldn't it still be worth it to do HINTS -examination in order to diagnose Vestibular neuritis?
Yes, a patient who has recovering vestibular neuritis can have an abnormal HIT after the nystagmus at rest has resolved. An astute clinician who sees this patient a week or so after the onset of symptoms can decide that the story sounds very much like recovering vestibular neuritis and decide to look for the an abnormal HIT, which if seen, would make the diagnosis. At this stage of the game, diagnosing it would be of no great advantage to the patient. However, they would not be doing the HIT in the context of the HINTS exam. It would be a stand alone test. In order words, they would not commit to calling this a central cause for the patient symptoms if they saw a normal HIT, no nystagmus and no skew deviation. This avoid raising concern for a central cause in cases of vestibular migraine or BPPV who complain of persistent dizziness. In fact, in dizzy clinics, where clinicians with vertigo expertise see patients, this is routinely done. They might also do a vHIT for this or other potential diagnoses. But if an emergency physician decides to apply the HINTS exam to a patient without nystagmus at rest in the first several days of their illness, those patient with vestibular migraine or BPPV who have no nystagmus at rest, but at times complain of constant dizziness will end up having a normal HIT, and if the HINTS is applied, unwarranted concern for a central cause would lead to unnecessary diagnostic imaging or acute referral for possible stroke.
Perfectly good question! A dizzy stroke is a stroke presenting with dizziness as one of the primary symptoms of a stroke. It most commonly happens in a stroke caused by a disruption in the posterior circulation of the brain. Often these patients can at first glance be suffering from a peripheral cause of vertigo such such as vestibular neuritis.
@@PeterJohnsi think he (she) meant, that in this situation we will have simultaneous central and peripheral features, e.g. positive head impulse test. But, like it was said in the video, we should start from central findings, and if we observe them, mri have to be performed. Other peripheral features shouldn't be even actively searched to not losing a time.
![[SFM] Risky Recital](http://i.ytimg.com/vi/RzNkY1_Nk3o/mqdefault.jpg)
Excellent video. Primary care doctor in UK. Is a struggle to find any clear guidance on no nystagmus with persistent dizziness now i understand why. So that was really useful alongside when not to use HINTS and why. Thank you!
Thanks so much for this. I rewatch it every few months. I work on a small Ed without easy access to MRI and it's clinical gold.
Hi Peter !
As always clearly and thoroughly explained with logical arguments! Where do I sign the petition for getting you , Drs Edlow, Newman-Toker and Kattah in the same room and discuss the 2% that you guys disagree about !?
Small comments / questions (it’s a bit long - sorry. And I have no expectation of getting an answer)
- 1) To HINTS plus or not : To my knowledge there’s no studies (and probably won’t be any) of the + / hearing loss part in HINTS+. Let’s say you have a patient testing negative central features , and the HINTS test suggest vestibular neuritis but the patient also has hearing loss (ruling in for HINTS+). I guess there’s no safe way other than an MRI to differentiate the AICA stroke from Labyrinthitis (in my experience they tend to have elevated inflammation makers as well , but probably that is not a specific enough finding to rule out the AICA)?
- 2) the “AVS+nystagmus”-like presentation in some BPPV patients: I think some of the confusion with application of HINTS lies in not knowing the data . But I think some of it may be as simple as interpreting what the patient is saying . “Constant dizzyness” is something I hear from some monosymptomatic dizzy patients with a history suggesting BPPV (even though it may be 10-20% of max dizzyness for the patient as opposed to the true “dizzy at baseline” patient with AVS who is maybe at 90-100% of max dizzyness when lying still). Now some of these BPPV patients may have some residual nystagmus if you are not careful in your instructions to them to not move their head for a couple of minutes (especially if they have cupolithiasis and not canalithiasis). So in my experience (which of course may be wrong) some dizzy patients with BPPV will have an “AVS + nystagmus”-like presentation. And I suggest in these cases to my colleagues that if the history and exam in all other aspects suggest BPPV, then I’d try to do the dix hallpike/ supine head roll to see if you get a clearly positive test.
- 3) The logistics: Do you have a video where you “real time” do the entire thing (how you ask the questions , in what order you do the exams and how the logistics look like)? I ask , because I feel like the devils with the reason why people for instance are not screening for neuro findings is because they don’t have a clear role model / pattern to follow. It’s not uncommonly difficult to do a thorough exam on the patients with dizzyness because of the nausea and vomiting - especially when you are within the window of thrombolysis and the clock is ticking. As I’ve detailed in my videos on dizzyness m.ruclips.net/video/1dZEAK062Iw/видео.html 26:00, we usually quickly screen for central features (and medical mimicks such as arythmias) + put in line and give ondansetrone and IV fluids -> place a hand on the head of the patient and take the history, making very sure they don’t move to the head for 2-5 minutes -> checking for spontaneous / gaze evoked nystagmus at around 30 degrees eye shift from midline (often helped by Frenzel)-> if nystagmus we do HINTS (unless the patient has a very BPPV like history and maybe slight but not obvious spontaneous nystagmus, then I may do the BPPV provocation manoeuvres occasionally as stated above, but if not clearly positive , then go to HINTS) , If no nystagmus we do BPPV tests -> if no nystagmus and no signs of BPPV only then I’ll get them sitting and on their feet (by now hopefully the drugs have kicked in so this is possible without too much vomiting) and see that they are not truncal ataxic (like you showed clearly in your video examples - can they walk unassisted or not). If their gate is worse than normal and I cannot find any other reason for it , it’s an Acute Instability Syndrome until proven otherwise and they’ll be admitted . Otherwise they’ll go home
- 4) Exclusion criterias for HINTS and false positive AIS patients: The patients that are NOT too good walkers at baseline (frail / elderly etc ) or patients who are drunk , would probably be false positive on the approach we advocate for because of their baseline nystagmus and / or gate instability and perhaps in these patients the tests could be used by a case by case basis , but one should be careful of ruling out central causes by bedside manoeuvres alone
- 5) HINTS with enucleated eyes with re-attached muscles to the prosthetics: we came across a patient with monosymptomatic constant dizzyness , but with bilateral eye enucleation and the gait was per usual? We went for an MRI on that patient that was normal , but curious if you had done it differently
All the best
Peter
Very nice and that makes significant change in my daily clinical practice about dizzy patients. Thanks so much.
Thank you Peter! Practicing clinicians sometimes have so many conflicting pieces of information in our head that beating the information into us is needed to shake the bad information loose. I'll find something other than the HINTS exam to do if a patient does not have persistent dizziness and nystagmus at rest. Like getting a cup of coffee...to give me more time to think.
Taking time is sometimes what is needed.
@@PeterJohnshello Doctor. Epley manuver helped me 2days ago, thank you very much😊
But I still feel little a bit disorientated, is that normal?
@@vinkosusac1130 Post maneuver dizziness is not uncommon. It usually clears up in a couple of days.
@@PeterJohns it’s already better, thank you 🙂
I have two more questions, If you don’t mind🙂
I am physical terapist and I do Manual therapy for neck, and sometimes vertigo wanish after I fix a neck! Do you think that vertigo with nistagmus has ever cervikal spine origin?
2. Do you consider By term “spontaneous nistagmus”, when someone is sitting or laying down( straight head or rotated), and watching complitly left or right, and we see miled nistagmus?
Thank you Doctor Johns.
@@vinkosusac1130 Cervical vertigo is a controversial topic, and I don't see those patients in the ED, or at least I don't recognize them as such, so I don't have much to say about it. 2. Spontaneous nystagmus is nystagmus when the patient is upright at rest and looking straight ahead. I now have started using the term "nystagmus at rest" which means looking straight ahead or looking 30 degrees left and right without fixation. If you lie someone down or turn their head, this is positional testing, and if typical nystagmus of BPPV is seen in either the Dix-Hallpike test or supine roll test, and typical story is there, and no other neuro signs or symptoms, then the diagnosis of BPPV is made.
Thanks!
Thank you very much!
@@PeterJohnsyou are really deserve it!❤
Excellent videos. My name is Yafit and I am a physical therapist from Israel.
I mainly treat people who suffer from acute and chronic dizziness. Always enjoy learning from your videos!
Thank you very much - I would be happy to host you in Israel (on calmer days :)
I hope one day to be able to come to Israel.
Emerg trainee here
Thanks
Loud and clear
Thanks for your videos. I would like to suggest that the HIT is useful to do on a patient without gaze nystagmus to assess for unilateral hypofunction. This is not in context of the ED environment where one might be ruling in or out life-threatening etiology, but is helpful in a physical therapy environment to create an exercise program to strengthen the overall system and decrease falls risk. (Herdman, 2011)
Absolutely! The HIT used in isolation, go ahead and use it any time you feel like it. But if are using it in the context of one part of the 3 part HINTS exam, and you're using it on patients who are newly dizzy and have no nystagmus at rest, many false positive will occur.
Very useful. Thank you
Dear Dr. Johns.
Great and professional video!
Hope you saw what we do. Could be useful to record eyes.
I try and keep it simple. Current cell phones are very good at recording eye movements.
@@PeterJohns We fully agree.
Thank you. This is the best information on HINTS I have ever found. Amazing. What are your thoughts on other dx of continuous/constant vertigo e.g. PPPD, mal de debarquement etc. Are HINTS useful in these cases? They frequently do not have spontaneous nystagmus, so I guess I already know what you'd say :D
Unless acute vestibular neuritis is part of the differential, using all 3 components of HINTS is not useful. And acute VN shouldn't be a concern in possible PPPD or mal de debarquement syndrome.
@peter
Hi Dr Peter , Your videos are really informative and have been of real help for me.. So firstly thank you .
Wanted to know, about pediatric BPPV.. I had a 11 yr old boy, with symptoms of rotatory giddiness, 2 episodes over a span of 1 month,. triggered by lying on the bed, no h/o headaches... On dix hallpike , he experienced giddiness on right side.. but there was no nystagmus . Do i treat it as BPPV.... ? Or.. is there something else that need to consider ..
I'm sorry, but I can't comment on your patients illness.
Thank you for this in-depth information. Question…Why was the Romberg done in the 2nd pt? I am thinking that the examiner is testing for balance, but romberg isn’t a cerebellar test…was it done as a vestibular evaluation ….what was the yield in this scenario?
It had no value in the evaluation of this man. You are right that it isn't a cerebellar test. In dizziness people tend to fall over when asked to stand with feet together and eyes open or closed when the dizziness is severe. If you spin yourself around 10 times quickly, you will have much difficult standing with your feet together. Some people are under the impression it has value in determining a central cause over a peripheral cause. I kind of showed this one to point out that it doesn't really help.
@@PeterJohns thanks for the quick response.
under rated video
Ha! I didn't know it was rated!
Hi Dr. Peter, I am a GP from Beijing, China. Most Chinese doctors cannot watch your fantastic vertigo videos because of network limitations
and language barriers. Can I forward your videos to one of the Chinese video websites (bilibili) and put the Chinese subtitle? Thank you, Peter!!!
Oh, one person from Russia just did it in the private neurological telegram channel with no even added subtitles. Who can get it - will get it!
Damn authoritarian leaders with their Internet locks and firewalls! Russia is heading the same way right now 😢
I'm sorry, but I can't give permission for my videos to be used in that manner.
Does the nystagmus at rest ( while looking straight ahead) and the nystagmus only on gaze deviation either left or right carry the same significance while subjecting them to HINTS examination? Thank you very much for the educative video.
perfect! thx very much
Excellent ❤
Hi Dr. Johns, I'm a novice medical student, so please forgive me for the very basic question, but I'm wondering how we should interpret gaze-evoked nystagmus (similar to what you mention at around 29 minute mark of the video) in a patient with continuous vertigo, but no spontaneous nystagmus (I.e. when at rest looking straight ahead). Should we also not do a HINTS exam on these patients? Based on the phrasing that we should only be doing HINTS exams on pts with acute vestibular syndrome and spontaneous nystagmus, my assumption is that the answer is NO, but just want to clarify. Thank you.
I consider "nystagmus at rest" to be any nystagmus that is not brought on by positional changes of the head, as in during a Dix-Hallpike test. So "nystagmus at rest" would include nystagmus that is seen when the patient is looking straight ahead (spontaneous nystagmus) and also nystagmus that is only seen when the patient is asked to look left or right 30 degrees. And it would be completely appropriate to perform the HINTS exam in any patient with new onset persistent vertigo and nystagmus at rest. Hope this clear it up.
@@PeterJohns thank you, sir! I’ve been watching your videos and have found them incredibly helpful. Do you have any recommendations for resources or even some of your other videos that talk about how the other less common causes of vertigo should fit into our diagnostic framework? For example, the tintinalli’s algorithm ends by saying “consider other causes” if the Dix-Hallpike maneuver is negative or abnormal. I mostly am finding some confusion as to where questions on history like recent ototoxic medication use (such as gentamicin) or recent head trauma (causing things like post-concussion syndrome or perilymphatic fistula) should fit in the diagnostic framework (should these things be considered after ruling out scary stuff on the Acute vestibular syndrome side of the algorithm or on the episodic vestibular syndrome side). Sorry for the long winded comment, but I greatly appreciate your time and insight!
@@maxgiesken9488 I specifically don't make videos about less common causes of vertigo. This is because most clinicians who haven't received some kind of vertigo training, beyond medical school or residency can't diagnose their way out of a paper bag when it comes to dizziness! Have you read the article by Lessing "Teaching more about less: Preparing clincians for practice". It explains why i do what I do. I can send you the article, it's very short.
Glad you have found my videos helpful. It's people like you, learning about vertigo at an early stage in your career, who are the hope for the future.
Gentamicin ototoxicity would likely produce bilateral abnormal HIT. Recent trauma can produce BPPV (multiple canals can be affected!). Post concussion syndrome is a diagnosis of exclusion, and by history. Third window problems, like perilymphatic fistula are quite rare. Here is an article if you are interested in that. www.ncbi.nlm.nih.gov/pmc/articles/PMC7963676/#:~:text=Third%20window%20abnormalities%20are%20defects,air%2Dbone%20gap%20by%20audiometry.
I sense you will become a vertigo champion!
Hi Peter!
So, to be clear, we SHOULD do the HINTS exam only if there is nystagmus at rest OR nystagmus EVOKED by gaze? Or do we only do it if there is nystagmus AT REST?
I consider nystagmus at rest to be any nystagmus that is not brought on by positional changes of the head, as in BPPV. So that would include nystagmus that is brought on by looking left or right 30 degrees with fixation removed.
@@PeterJohnsthank you a lot!
Hello, a question please; Can a patient have a positive head impulse test (With catch-up saccades) , although they present with no nystagmus at rest?
If the answer is yes - wouldn't it still be worth it to do HINTS -examination in order to diagnose Vestibular neuritis?
Yes, a patient who has recovering vestibular neuritis can have an abnormal HIT after the nystagmus at rest has resolved. An astute clinician who sees this patient a week or so after the onset of symptoms can decide that the story sounds very much like recovering vestibular neuritis and decide to look for the an abnormal HIT, which if seen, would make the diagnosis. At this stage of the game, diagnosing it would be of no great advantage to the patient.
However, they would not be doing the HIT in the context of the HINTS exam. It would be a stand alone test. In order words, they would not commit to calling this a central cause for the patient symptoms if they saw a normal HIT, no nystagmus and no skew deviation. This avoid raising concern for a central cause in cases of vestibular migraine or BPPV who complain of persistent dizziness.
In fact, in dizzy clinics, where clinicians with vertigo expertise see patients, this is routinely done. They might also do a vHIT for this or other potential diagnoses.
But if an emergency physician decides to apply the HINTS exam to a patient without nystagmus at rest in the first several days of their illness, those patient with vestibular migraine or BPPV who have no nystagmus at rest, but at times complain of constant dizziness will end up having a normal HIT, and if the HINTS is applied, unwarranted concern for a central cause would lead to unnecessary diagnostic imaging or acute referral for possible stroke.
I’m sorry but what is a Dizzy stroke? 😂 med student here. Sorry for dumb question
Perfectly good question! A dizzy stroke is a stroke presenting with dizziness as one of the primary symptoms of a stroke. It most commonly happens in a stroke caused by a disruption in the posterior circulation of the brain. Often these patients can at first glance be suffering from a peripheral cause of vertigo such such as vestibular neuritis.
What about unilateral chronic vestibular hypoactivity with stroke
What exactly is your question?
@@PeterJohnsi think he (she) meant, that in this situation we will have simultaneous central and peripheral features, e.g. positive head impulse test. But, like it was said in the video, we should start from central findings, and if we observe them, mri have to be performed. Other peripheral features shouldn't be even actively searched to not losing a time.
Probably due to a lack of understanding of neurology, foundational neuroanatomy and an over reliance on imaging.
Yes, and decades of poor vertigo education. Frankly, many neurologists and ENT specialists aren't very good at vertigo either.
As a radiologist once told me “ No one will ever thank you for not having done imaging on them”. All the incentives are in the opposite direction