Training in VNG
Skew Deviation in HINTS Protocol: Next Step?
Description
Firstly, it is important to remember that skew deviation is not only present in central disorders, you might find a very tiny skew deviation in vestibular neuritis also - particularly if you search for it. i.e. If you ask the patient if there's any position at all, where he/she is seeing double, or if we do a rigorous cover and cover testing. So, remember skew might happen in peripheral disorder. Still, most of the times it will reflect a central disorder. If you see a skew, then you should be interested in evaluating the rest of the parameters on HINTS protocol, what are the head impulse results? Is there the presence of gaze evoked nystagmus? Is there a spontaneous nystagmus? Is there an acute hearing impairment? These findings may support either a stroke or a vestibular neuritis depending on the findings. I do find HINTS protocol extremely helpful as a starting point. However, note that HINTS algorithm has been mostly applied in vestibular stroke and vestibular neuritis patients. But in the acute setting, you have many other patients with vestibular migraine attacks, Meniere’s attacks, and occasionally BPPV patients with pseudo spontaneous nystagmus that might mimic an acute vestibular syndrome. So, in real life is not only about two disorders.
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