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Chapter 5

Lit Matters 2: HINTS Exam

Matt Delaney, MD and Salim Rezaie, MD
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Nicholas H. -

I think one if the things that gets lost in the discussion here is just how bad MRI is. While HINTS overall (including EPs) was only 80% sensitive for posterior stroke, believe it or not that’s roughly the same sensitivity as an MRI for posterior stroke within the first 48 hours. After 48 hours it’s roughly 100% (of course there’s some incorporation bias there, but the point is still MRI will miss 20% of posterior strokes unless you wait 2 days). At least at my shop (and I would imagine just about everywhere this is true) if I admit a patient for concern of posterior stroke they’re getting their MRI within the first day then being discharged if it’s negative (see the original HINTS paper, the references are in there). Hence there’s an irony - if I stop using HINTS and admit every acute vestibular syndrome patient, they will likely just stay 1 day to get a test that is just as bad as my HINTS exam but costs more and probably causes false reassurance.

I don’t know what the answer is - clearly the limited evidence here suggests that HINTS is variable based on experience - but I think it’s always important to consider the alternative before discarding a test or clinical strategy. In this case, that alternative may be just as bad and cost the patient a lot more.

Rob O., MD -

What a fantastic point. Thanks for putting that together. I wish there were an equally excellent answer, but you've hit the nail on the head. Here's what Salim had to say...

No test or exam finding is 100%...the point of the lit review on this paper is to make clinicians aware that HINTS is not the end all be all. It is a difficult and tedious exam finding that requires lots of practice. It is cheaper and will catch some posterior strokes. If you are not convinced that you are doing the HINTS exam well or don't feel facile in it, the best approach is a conservative one with neurology consultation and MR Brain. Granted this strategy will miss some posterior circulation strokes as well, but with HINTS, Neuro consult, and MR Brain the chances of missing go way down compared to HINTS or MR Brain alone.

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