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We do not know the sensitivity of the test in this population. The study has not yet been validated by a large external group, let alone a large external group of emergency medicine providers. In the derivation study, it was performed by one practitioner who was a neuro-ophthalmologist using specialized equipment to measure skew. If, for example, the patient has horizontal rightward nystagmus with right gaze and no skew, but has no findings on impulse test, you cannot invoke the HiNTs exam to clear the patient If the HiNTs exam is entirely consistent with peripheral vertigo (positive head impulse test, unidirectional and horizontal nystagmus, negative test of skew), then, according to the derivation paper, it is 100% sensitive and 96% specific for a peripheral cause of vertigo. While this sounds appealing, there are some caveats:ĪLL findings must be present for the HiNTs exam to be invoked. A positive result will be the deviation of one eye while it is being covered, followed by correction after uncovering it. Alternate covering each of the patient’s eyes. If, for example, a patient has right-beating (fast direction to the right) nystagmus with rightward gaze and leftward gaze, this is unidirectional right-beating nystagmus.īidirectional nystagmus, I.E fast component to the right with rightward gaze and to the left with leftward gaze, is concerning for a central process, as is vertical nystagmus or pure torsional nystagmus.Īgain have the patient maintain his/her gaze on your nose. What direction is the fast component? If the nystagmus is worse looking in one direction, with the fast component present in that same direction on contralateral gaze, it is unidirectional and reassuring for peripheral vertigo. looking straight ahead) and/or in lateral gaze. Note if nystagmus is present in primary gaze (i.e. An acceptable alternative is assessing for ocular dysmetria. In addition, one should avoid this in patients with known severe carotid stenosis as it may embolize unstable plaque. False negatives often result from an inexperienced practitioner being too gentle with the head thrust due to fear of causing neck injury.Ĭontraindications: Any patient that has head trauma, neck trauma, an unstable spine, or neck pain concerning for arterial dissection. Likewise, anxious patients who are unable to relax their neck are unable to do this procedure adequately. Patients who are mentally impaired, unable to fixate, or sedated cannot do this maneuver. This is essentially an awake “doll’s eye” that requires conscious fixation on an object. Pitfalls: The patient must be awake and cooperative.
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A lag in corrective saccades in the vertical plane is always suspicious for a central etiology for vertigo. If there is a lag in corrective saccades in both directions, it may be concerning for central vertigo. This test can also be performed in the vertical plane. The horizontal head impulse test is consistent with peripheral vertigo if it is positive in one direction only. Compare this to the contralateral side a difference in the speed of correction should be noted. Video for Good Technique If you can see the correction, it is abnormal.
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The head impulse test is positive (consistent with peripheral vertigo) if there is a significant lag with corrective saccades. The patient may have a small corrective saccade. Gently move the patient’s head to one side, then rapidly move it back to the neutral position. Ask the patient to relax his/her head and maintain his/her gaze on your nose.