Acute Vertigo (HINTS) — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Does HINTS suggest central?
   Persistent acute vestibular syndrome (AVS) — does HINTS suggest central? (AVS = persistent vertigo (>24 h) + nausea/vomiting + nystagmus + gait instability, ~25% are posterior-circulation stroke. HINTS is only for persistent AVS, not BPPV (positional/episodic). Three steps: 1) head impulse test normal = central (counterintuitive), corrective saccade = peripheral; 2) nystagmus direction-changing/vertical = central, unidirectional horizontal = peripheral; 3) skew deviation (alternate cover) present = central. Central mnemonic INFARCT. HINTS-Plus: new unilateral hearing loss = central. Requires a trained examiner.)
   • Any central sign / hearing loss (central) → Central sign → work up as stroke
   • All three peripheral → All three peripheral · vestibular neuritis
2. [End] All three peripheral · vestibular neuritis
   Abnormal head impulse + unidirectional nystagmus + no skew = vestibular neuritis: symptomatic care (short-term antiemetic/vestibular suppressant, vestibular rehabilitation); observe closely, image if signs change or the picture is atypical.
3. [End] Central sign → work up as stroke
   Any central sign (normal head impulse / direction-changing or vertical nystagmus / skew / new hearing loss) or inability to reliably perform HINTS: work up as posterior-circulation stroke — MRI (DWI may be falsely negative early), CTA/MRA, manage along the stroke pathway; CT only excludes hemorrhage and is insensitive to the posterior fossa.

Source guidelines & references

• HINTS exam (Kattah/Newman-Toker 2009); evaluation of acute vestibular syndrome

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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