SynthesisJournal of neurology2026
HINTS+ to diagnose AICA stroke: systematic review of the diagnostic impact of acute unilateral hearing loss in the acute vestibular syndrome.
Synthesis in Journal of neurology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
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Who cites it
1 citing paper in PubMed.
- The state of vestibular neurology: Diagnostic challenges and emerging opportunities.Science progressReview
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6 authors.
Funding
Abstract
purposeHead-Impulse, Nystagmus, Test-of-Skew (HINTS) testing is recommended to identify stroke in the acute vestibular syndrome (AVS). Diagnostic accuracy depends on the vascular territory involved, with lower sensitivity for anterior-inferior cerebellar artery (AICA)- than posterior-inferior cerebellar artery (PICA)-territory strokes. Adding new-onset, acute unilateral hearing loss (AUHL) as a fourth central sign has been proposed ("HINTS+") to improve sensitivity for AICA-stroke detection.
methodsWe performed a systematic search (MEDLINE, Embase) to identify studies reporting diagnostic accuracy of bedside examination in AVS patients, including the diagnostic impact of HINTS+. Results were stratified by stroke location.
resultsWe identified 4388 citations and included 11 articles (n = 770 patients). Ischemic strokes (n = 319) and acute unilateral vestibulopathy (n = 391) were the most frequent causes. AUHL was most often assessed by finger rub (n = 311), tuning-fork tests (n = 114), or whispered words (n = 169), and was present in 50 patients (central = 29, peripheral = 21). Bedside head-impulse testing was abnormal in 25/29 central cases with AUHL, with 19/25 cases demonstrating an AICA-stroke. Diagnostic accuracy of HINTS (sensitivity = 92.7% [88.7-96.8%]; specificity = 91.1% [86.3-95.8%]) was high. Adding AUHL (HINTS+) increased sensitivity (95.7% [92.7-98.7%]) but decreased specificity (80.7% [70.6-90.7%]), though the latter was largely from bias in patient selection. AUHL had the biggest impact for AICA-territory strokes, increasing sensitivity from 73.3% (59.0-84.0%) to 91.1% (79.3-96.5%).
conclusionsTesting for AUHL in AVS increased stroke-sensitivity, but this effect was mainly related to AICA-strokes with abnormal head-impulse testing (n = 19/22), where adding AUHL yielded an absolute increase of 17.8% in stroke-sensitivity. In AVS, AUHL should be assessed at the bedside (and ideally confirmed by audiometry).
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