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Acute vestibular syndrome: clinical head impulse test versus video head impulse test


HINTS battery involving head impulse test (HIT), nystagmus, and test of skew is the critical bedside examination to differentiate acute unilateral peripheral vestibulopathy from posterior circulation stroke (PCS) in acute vestibular syndrome (AVS). The highest sensitivity component of the battery has been reported to be the horizontal HIT, whereas skew deviation is defined as the most specific but non-sensitive sign for PCS. Video-oculography-based HIT (vHIT) may have an additional power in making the differentiation. If vHIT is undertaken, then both gain and gain asymmetry should be taken into account as anterior inferior cerebellar artery (AICA) strokes are at risk of being misclassified based on VOR gain alone. Further refinement in video technology, increased operator proficiency and incorporation with saccade analysis will increase the sensitivity of vHIT for PCS diagnosis. For the time being, clinical examination seems adequate in frontline diagnostic evaluation of AVS.

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  1. Hotson JR, Baloh RW (1998) Acute vestibular syndrome. N Engl J Med 339:680–685

    Article  CAS  Google Scholar 

  2. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE (2011) Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 183:E571–E592

    Article  Google Scholar 

  3. Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ (2008) Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 70:2378–2385

    Article  Google Scholar 

  4. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 40:3504–3510

    Article  Google Scholar 

  5. Paul NL, Simoni M, Rothwell PM (2013) Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol 12:65–71

    Article  Google Scholar 

  6. Kim SH, Kim HJ, Kim JS (2017) Isolated vestibular syndromes due to brainstem and cerebellar lesions. J Neurol 264(Suppl 1):63–69

    Article  Google Scholar 

  7. Newman-Toker D, Kerber K, Hsieh Y et al (2013) HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 20:986–996

    Article  Google Scholar 

  8. Kerber KA, Meurer WJ, Brown DL, Burke JF, Hofer TP, Tsodikov A, Hoeffner EG, Fendrick AM, Adelman EE, Morgenstern LB (2015) Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study. Neurology 85:1869–1878

    Article  Google Scholar 

  9. Newman-Toker DE, Saber Tehrani AS, Mantokoudis G, Pula JH, Guede CI, Kerber KA, Blitz A, Ying SH, Hsieh YH, Rothman RE, Hanley DF, Zee DS, Kattah JC (2013) Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke 44:1158–1161

    Article  Google Scholar 

  10. Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Strupp M (2008) Bedside differentiation of vestibular neuritis from central “vestibular pseudoneuritis”. J Neurol Neurosurg Psychiatry 79:458–460

    Article  CAS  Google Scholar 

  11. Halmagyi GM, Curthoys IS (1988) A clinical sign of canal paresis. Arch Neurol 45:737–739

    Article  CAS  Google Scholar 

  12. Beynon GJ, Jani P, Baguley DM (1998) A clinical evaluation of head impulse testing. Clin Otolaryngol Allied Sci 23:117–122

    Article  CAS  Google Scholar 

  13. Reiss M, Reiss G (2012) Vestibuler neuritis: is there any evidence of an asymmetric distribution? Eur Arch Otorhinolaryngol 269:1091–1094

    Article  Google Scholar 

  14. Guler A, Karbek Akarca F, Eraslan C, Tarhan C, Bilgen C, Kirazli T, Celebisoy N (2017) Clinical and video head impulse test in the diagnosis of posterior circulation stroke presenting as acute vestibular syndrome in the emergency department. J Vestib Res 27:233–242

    Article  Google Scholar 

  15. Weber KP, Aw ST, Todd MJ, McGarvie LA, Curthoys IS, Halmagyi GM (2008) Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. Neurology 70:454–456

    Article  CAS  Google Scholar 

  16. Jorns-Häderli M, Straumann D, Palla A (2007) Accuracy of the bedside head impulse test in detecting vestibular hypofunction. J Neurol Neurosurg Psychiatry 78:1113–1118

    Article  Google Scholar 

  17. Mantokoudis G, Tehrani AS, Wozniak A, Eibenberger K, Kattah JC, Guede CI, Zee DS, Newman-Toker DE (2015) VOR gain by head impulse video-oculography differentiates acute vestibular neuritis from stroke. Otol Neurotol 36:457–465

    Article  Google Scholar 

  18. Chen L, Todd M, Halmagyi GM, Aw S (2014) Head impulse gain and saccade analysis in pontine-cerebellar stroke and vestibular neuritis. Neurology 83:1513–1522

    Article  Google Scholar 

  19. MacDougall HG, Weber KP, McGarvie LA, Halmagyi GM, Curthoys IS (2009) The video head impulse test: diagnostic accuracy in peripheral vestibulopathy. Neurology 73:1134–1141

    Article  CAS  Google Scholar 

  20. Roberts HN, McGuigan S, Infeld B, Sultana RV, Gerraty RP (2016) A video-oculographic study of acute vestibular syndromes. Acta Neurol Scand 134:258–264

    Article  CAS  Google Scholar 

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Correspondence to Nese Celebisoy.

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This manuscript is part of a supplement sponsored by the German Federal Ministry of Education and Research within the funding initiative for integrated research and treatment centers.

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Celebisoy, N. Acute vestibular syndrome: clinical head impulse test versus video head impulse test. J Neurol 265 (Suppl 1), 44–47 (2018).

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