Can emergency physicians accurately rule out a central cause of vertigo using the HINTS exam? A systematic review and meta-analysis.

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Can emergency physicians accurately rule out a central cause of vertigo using the HINTS exam? A systematic review and meta-analysis.

Acad Emerg Med. 2020 Mar 13;:

Authors: Ohle R, Montpellier RA, Marchadier V, Wharton A, McIsaac S, Anderson M, Savage D

Abstract
INTRODUCTION: Dizziness is a common complaint presented in the emergency department. A subset of these patients will present with acute vestibular syndrome (AVS). AVS is a clinical syndrome defined by the presence of vertigo, nystagmus, head motion intolerance, ataxia, and nausea/vomiting. These symptoms are most often due to benign vestibular neuritis; however, can be a sign of a dangerous central cause i.e. vertebrobasilar stroke. The Head Impulse test, Nystagmus, Test of Skew (HINTS ) exam has been proposed as a bedside test for frontline clinicians to rule out stroke in those presenting with AVS. Our objective was to assess the diagnostic accuracy of the HINTS exam to rule out a central cause of vertigo in an adult population presenting to the emergency department with AVS. Our aim was to assess the diagnostic accuracy when performed by emergency physicians versus neurologists.
METHODS: We searched PubMed, Medline, Embase, the Cochrane database, relevant conference abstracts from 2009 to September 2019 and performed hand searches. No restrictions for language or study type were imposed. Prospective studies with patients presenting with AVS using gold standard of CT and/or MRI were selected for review. Two independent reviewers extracted data from relevant studies. Studies were combined if low clinical and statistical heterogeneity was present. Study quality was assessed using the QUADAS-2 tool. Random effects meta-analysis was performed using Revman 5 and SAS 9.3.
RESULTS: A total of 5 studies with 617 participants met the inclusion criteria. The average study length was 5.3 years (SD 3.3 years). Prevalence of vertebrobasilar stroke ranged 9.3-44% (Mean 39.1% SD 17.1). The most common diagnoses were vertebrobasilar stroke (Mean 34.8% SD 17.1%), peripheral cause (Mean 30.9% SD 16%) and Intracerebral hemorrhage (Mean 2.2%, SD 0.5%). The HINTS exam when performed by neurologists had a sensitivity of 96.7% (CI 95% 93.1 - 98.5), I2- 0%, Specificity 94.8% (CI 95% 91- 97.1%) I2 0% . When performed by a cohort of physicians including both emergency physicians (board certified) and neurologists(fellowship trained in neuro-otology or vascular neurology) the sensitivity was 83% (95%CI 63-95) specificity 44%(95%CI 36-51).
CONCLUSIONS: The HINTS exam when used in isolation by emergency physicians has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS.

PMID: 32167642 [PubMed - as supplied by publisher]

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