15/02/2026
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ЁЭЧаЁЭЧоЁЭШАЁЭШБЁЭЧ▓ЁЭЧ┐ЁЭЧ╢ЁЭЧ╗ЁЭЧ┤ ЁЭШБЁЭЧ╡ЁЭЧ▓ ЁЭЧЫ.ЁЭЧЬ.ЁЭЧб.ЁЭЧз.ЁЭЧж. ЁЭЧШЁЭШЕЁЭЧоЁЭЧ║ ЁЭЧ│ЁЭЧ╝ЁЭЧ┐ ЁЭЧФЁЭЧ░ЁЭШВЁЭШБЁЭЧ▓ ЁЭЧйЁЭЧ▓ЁЭШАЁЭШБЁЭЧ╢ЁЭЧпЁЭШВЁЭЧ╣ЁЭЧоЁЭЧ┐ ЁЭЧжЁЭШЖЁЭЧ╗ЁЭЧ▒ЁЭЧ┐ЁЭЧ╝ЁЭЧ║ЁЭЧ▓
тмЫ When a patient presents with Acute Vestibular Syndrome (AVS)тАФdefined as sudden-onset constant vertigo accompanied by nausea/vomiting, gait unsteadiness, and spontaneous nystagmusтАФdistinguishing between a benign inner ear issue (peripheral) and a dangerous stroke (central) is critical
тмЫ Enter the H.I.N.T.S. exam
тмЫ This three-step bedside oculomotor test stands for Head Impulse, Nystagmus, Test of Skew
тмЫ Surprisingly, this physical exam can be more sensitive than a hyperacute MRI for identifying central causes of AVS
ЁЭЧЫ тАФ ЁЭЧЫЁЭЧ▓ЁЭЧоЁЭЧ▒ ЁЭЧЬЁЭЧ║ЁЭЧ╜ЁЭШВЁЭЧ╣ЁЭШАЁЭЧ▓ ЁЭЧзЁЭЧ▓ЁЭШАЁЭШБ (HIT) ЁЯСБя╕П
тмЫ This maneuver tests the vestibulo-ocular reflex
ЁЯФ╣ Peripheral Sign:
тмЫ You see a catch-up saccade
тмЫ When the head is turned rapidly, the eyes lose the target and must make a corrective movement (saccade) to re-fixate
тмЫ This abnormal finding typically implies peripheral pathology
ЁЯФ╣ Central Sign:
тмЫ The eyes maintain fixation perfectly during the impulse
тмЫ A "normal" response in a dizzy patient is actually worrisome for a central cause
ЁЭЧб тАФ ЁЭЧбЁЭШЖЁЭШАЁЭШБЁЭЧоЁЭЧ┤ЁЭЧ║ЁЭШВЁЭША ЁЯСА
тмЫ Observe the patient's eye movements in different gazes
ЁЯФ╣ Peripheral Sign:
тмЫ Nystagmus is unidirectional in all gazes
тмЫ Always beating right, even when looking left
ЁЯФ╣ Central Sign:
тмЫ Nystagmus that is direction-changing
тмЫ Beats left when looking left, right when looking right
тмЫ Purely vertical
тмЫ Purely torsional
ЁЭЧз тАФ ЁЭЧзЁЭЧ▓ЁЭШАЁЭШБ ЁЭЧ╝ЁЭЧ│ ЁЭЧжЁЭЧ╕ЁЭЧ▓ЁЭШД тЖХя╕П
тмЫ Perform a cross-cover test to check for vertical ocular misalignment
ЁЯФ╣ Peripheral Sign:
тмЫ No vertical skew
тмЫ Eyes stay aligned
ЁЯФ╣ Central Sign:
тмЫ Vertical skew deviation
тмЫ One eye drifts up/down when covered
тмЫ This finding is highly suspicious for central pathology
ЁЭЧзЁЭЧ╡ЁЭЧ▓ ЁЭЧХЁЭЧ╝ЁЭШБЁЭШБЁЭЧ╝ЁЭЧ║ ЁЭЧЯЁЭЧ╢ЁЭЧ╗ЁЭЧ▓ тАФ "ЁЭЧЬЁЭЧбЁЭЧЩЁЭЧФЁЭЧеЁЭЧЦЁЭЧз" ЁЭШГЁЭША. ЁЭЧХЁЭЧ▓ЁЭЧ╗ЁЭЧ╢ЁЭЧ┤ЁЭЧ╗ тЪая╕П
ЁЯЯв To diagnose a Peripheral cause, the patient
must meet ALL three criteria:
тмЫ Present corrective saccade on HIT
тмЫ Unidirectional nystagmus
тмЫ Absent skew deviation
ЁЯФ┤ If the patient displays ANY one of the
following, you must rule out a Central cause (like a stroke):
тмЫ Absent saccade on HIT (eyes maintain fixation)
тмЫ Any other type of nystagmus (direction-changing, vertical, etc.)
тмЫ Present vertical skew deviation
ЁЯСЙ Remember, central pathology cannot be excluded if even a single finding is inconsistent with a peripheral localization