A 65-year-old presents with sudden severe vertigo, nausea, inability to walk, and ipsilateral limb ataxia. There is no hearing loss. The HiNTs (Head Impulse, Nystagmus, Test of Skew) examination shows a NORMAL (negative) head impulse test and skew deviation. What does this suggest?

• A Peripheral labyrinthine disorder (acute vestibular neuritis) — safe to discharge
• B BPPV with canalith displacement — Epley maneuver indicated
• C Bilateral labyrinthitis — vestibular physiotherapy
• D Central cause (likely cerebellar or posterior fossa stroke) — immediate brain MRI/DWI warranted ✓

Explanation

The HiNT examination distinguishes peripheral from central acute vertigo: a NORMAL (negative) head impulse test in the setting of acute vestibular syndrome is a red flag for CENTRAL pathology (the VOR is intact, so there is no peripheral end-organ failure). Combined with the presence of skew deviation (vertical ocular misalignment), direction-changing nystagmus, or cerebellar signs, this strongly indicates posterior fossa stroke or central lesion requiring emergent DWI-MRI. In peripheral vestibular neuritis, the head impulse test is POSITIVE (catch-up saccade toward the lesioned side).

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.