A 58-year-old man presents with continuous vertigo of acute onset. In the HINTS examination, which single component finding carries the strongest weight in predicting a central (stroke) cause?

• A Nystagmus that suppresses with visual fixation
• B Direction-fixed horizontal nystagmus obeying Alexander's law
• C Positive Dix-Hallpike test producing transient upbeat torsional nystagmus
• D A normal head impulse test with no corrective saccade ✓

Explanation

An acute peripheral lesion impairs the vestibulo-ocular reflex, giving an abnormal head impulse test with catch-up saccades. A normal head impulse test in acute vestibular syndrome implies the reflex is intact because the brainstem or cerebellum is compensating, which points strongly to a central lesion such as posterior circulation infarction. Fixation suppression (option A) actually favours peripheral disease, since central nystagmus typically fails to suppress with fixation.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.