BACKGROUND: Acute vestibular syndrome (AVS) often arises from benign peripheral causes, yet the critical need to distinguish dangerous causes, notably stroke, persists. The Head Impulse test, Nystagmus, Test of Skew (HINTS) examination has emerged as a bedside test to identify stroke. HINTS plus hearing loss and video-oculography-HINTS (v-HINTS) have gained traction for stroke diagnosis. This systematic review and meta-analysis aims to assess the accuracy of the "HINTS family" of tests (HINTS, HINTS plus, v-HINTS) in diagnosing stroke in AVS.

METHOD: We searched PubMed, Embase, Web of Science, and Cochrane library for prospective studies involving AVS patients diagnosed using MRI and/or CT as the gold standard. Two authors independently screened articles, extracted data, and assessed study quality using QUADAS-2. A meta-analysis was performed using STATA (12.0) and RevMan 5.3.

RESULTS: We included 11 studies in the analysis: 11 for HINTS (n = 1286), 2 for HINTS plus (n = 265), and 1 for v-HINTS (n = 50). Their sensitivities for stroke were 0.97 (95 %CI: 0.94-0.99), 0.99 (0.95-1.00) and 1.00, with specificities of 0.81 (0.72-0.88), 0.82 (0.74-0.88), and 0.90, respectively. LR+ for stroke were 5.2 (95 %CI: 3.3-8.2), 5.5 (3.8-8.2) and 9.75. Youden index were 0.78, 0.81 and 0.90. The AUC for HINTS and HINTS plus in diagnosing stroke were 0.98 and 0.99.

CONCLUSION: "HINTS Family" examinations are generally effective in detecting stroke in AVS patients, especially those with stroke risk factors. HINTS plus outperforms the HINTS examination. Furthermore, v-HINTS exhibits the highest accuracy, highlighting the importance of using VOG devices for acute stroke diagnosis.

Emergency Medicine rater

This meta-analysis of 11 studies evaluated HINTS, HINTS plus, and v-HINTS for diagnosing stroke. They found sensitivities of 0.97, 0.99, and 1.00, with specificities of 0.81, 0.82, and 0.90, respectively, for stroke diagnosis. However, this meta-analysis included only 2 studies for HINTS plus and 1 study of v-HINTS, and there may be heterogeneity. Clinicians must be knowledgable of when and how to use these tests. When used appropriately, they serve as valuable tools in assessing posterior circulation stroke.

Emergency Medicine rater

Not surprisingly, HINTS (and the variations HINTS-plus and v-HINTS) performed very well. However, there are limitations that need to be addressed before generalization can occur: 1) most of the studies were performed by experts in HINTS; 2) the number of studies included for HINTS-plus and v-HINTS was very small; 3) there is variability in terms of the patient cohort, which can make it difficult to know to which patient population to apply these tests. Since many generalists (e.g., emergency physicians) are not comfortable performing HINTS (and vog-assistance is not widely available), more studies are needed looking at how to enhance more end-users to get comfortable, without having to spend 4-6 hours of dedicated education.