Using "HINTS family" to diagnose stroke in the acute vestibular syndrome: A systematic review and meta-analysis

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.

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.

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.

"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.