Diagnostic algorithm for differentiating vestibular neuritis from stroke in patients with AVS. This sequence of testing is largely based on the HINTS model, but the sequence is different (see text for reasons) and there are 2 additional components: targeted neurologic examination that is specifically directed toward the cerebellum and brainstem, and testing for truncal and gait ataxia. 


I recommend these other components of the diagnostic algorithm because HINTS testing has not been validated when used by emergency physicians under routine circumstances. In one study, adding gait testing to the HINTS examination plus hearing yielded 100% sensitivity for stroke.41 Furthermore, testing gait in any dizzy patient is important to ensure a safe disposition, even if the cause is peripheral. CNS, Central nervous system; PCP, primary care physician; AVS, acute vestibular syndrome; HINTS, Head Impulse Test, Nystagmus, and Test of Skew.


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