The HINTS examination (Head Impulse, Nystagmus, Test of Skew) is used to differentiate acute vestibular neuritis from posterior circulation stroke. Which combination is indicative of a CENTRAL cause?

• A Abnormal head impulse test, unidirectional nystagmus, absent skew deviation
• B Abnormal head impulse test, direction-changing nystagmus, absent skew deviation
• C Normal head impulse test, unidirectional nystagmus, absent skew deviation
• D Normal head impulse test, direction-changing nystagmus, presence of skew deviation ✓

Explanation

In the HINTS battery, a NORMAL head impulse test (HIT) means the vestibulo-ocular reflex is intact and the lesion is more likely central; direction-changing nystagmus (with different beating direction on gaze) is a central sign; and skew deviation (vertical ocular misalignment) indicates brainstem involvement. This triad — normal HIT + direction-changing nystagmus + skew deviation — indicates a posterior fossa stroke. Peripheral vestibular neuritis shows abnormal HIT, unidirectional nystagmus, and no skew deviation.

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

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Written and medically reviewed by the StethoPrep medical team.