Board Review: Lets get cerebral


A 70-year-old male smoker with a history of hypertension and diabetes presents to the ED with dizziness. He reports that he was at work approximately one hour ago when all of a sudden “the room started spinning” associated with one episode of emesis. Coworkers called 911 when they witnessed him walking down the hallway holding onto the wall. Vital signs are normal. He says he has never felt this way before. What is the most sensitive test for your top differential diagnosis?


A. CTA head/neck

B. MRI brain with diffusion 

C. Dix-Hallpike Maneuver

D. HINTS exam






















Answer is D. This patient has symptoms highly concerning for a posterior circulation stroke. The HINTS exam (Head Impulse, Nystagmus, Test of Skew) is the most sensitive test for this diagnosis with a sensitivity approaching 100% in recent literature. Although you will likely order an MRI as part of your stroke alert protocol in consultation with neurology, it has been reported that MRI within 48 hours of infarction may miss up to 10-20% of posterior circulation strokes for high risk patients. A Dix-Hallpike maneuver is helpful for both diagnosing and treating BPPV however this patient’s presentation is more concerning for central etiology that must be pursued first.


See this prior EM daily post covering the HINTS exam: