Acute Vertigo Evaluation (HINTS & BPPV)

Algorithm Steps

1. ▶

   Start

   Acute Vertigo / Dizziness

   Patient presents with vertigo (room spinning), dizziness, or imbalance.

   1. ◆

      Decision

      Classify Vestibular Syndrome

      AVS: Continuous dizziness >24h with nystagmus. Triggered EVS: Brief episodes with head movement. Spontaneous EVS: Episodes without trigger.

      1. ●

         Action

         Triggered EVS → Suspect BPPV

         Brief vertigo (<1 min) triggered by head position changes. 90% of triggered EVS is BPPV. Perform Dix-Hallpike test.

         1. ●

            Action

            Dix-Hallpike Test

            Patient sitting, turn head 45°, rapidly lie back with head hanging. Watch for upbeat-torsional nystagmus with latency (2-20 sec). Positive = posterior canal BPPV.

            1. ◆

               Decision

               Dix-Hallpike Positive?

               Upbeat-torsional nystagmus with latency confirms posterior canal BPPV.

               1. ●

                  Action

                  Epley Maneuver (CRP)

                  Canalith Repositioning: Turn head 90° to opposite side, roll onto that side, sit up slowly. Hold each position 30 seconds. 70-80% success rate.

                  1. ✓

                     Outcome

                     BPPV Treated

                     Symptoms usually resolve immediately. Can recur (30-50%). Teach home Epley if recurrent.

               2. ●

                  Action

                  AVS: Check for Nystagmus

                  Acute Vestibular Syndrome with continuous symptoms. Look for spontaneous nystagmus. If present → HINTS exam.

                  1. ◆

                     Decision

                     Nystagmus Present?

                     HINTS exam only valid if spontaneous nystagmus is present.

                     1. ●

                        Action

                        Perform HINTS Exam

                        H: Head Impulse. I: Nystagmus type. TS: Test of Skew. HINTS is 92.9% sensitive for stroke - BETTER than MRI in first 48 hours.

                        1. ◆

                           Decision

                           HINTS Result?

                           PERIPHERAL: Positive head impulse + direction-fixed nystagmus + no skew. CENTRAL: ANY of negative head impulse, direction-changing nystagmus, or skew.

                           1. ●

                              Action

                              Peripheral: Vestibular Neuritis

                              Supportive care, antiemetics PRN (limit 2-3 days). Consider short-term steroids. Vestibular rehabilitation.

                              1. ✓

                                 Outcome

                                 Vestibular Neuritis Recovery

                                 Most recover in 1-3 weeks. Vestibular PT accelerates recovery. Follow-up with ENT.

                           2. ⚠

                              Warning

                              ⚠️ Central: Suspect Stroke

                              HINTS central = posterior circulation stroke until proven otherwise. Activate stroke protocol. MRI (not CT). Neurology STAT.

                              1. ●

                                 Action

                                 Stroke Workup

                                 MRI brain with DWI. CTA head/neck. Consider thrombolysis if within window. Admit to stroke unit.

                              2. ⚠

                                 Warning

                                 ⚠️ CT is NOT Adequate

                                 GRACE-3: Do NOT use CT to rule out stroke in AVS. CT sensitivity only 29% for posterior fossa stroke. MRI required.

                     2. ●

                        Action

                        No Nystagmus: Other Causes

                        Consider: Orthostatic hypotension, cardiac arrhythmia, medication effects, anemia, hypoglycemia, anxiety.