Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis
Citation Manager Formats
Make Comment
See Comments
This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
Abstract
Objective: To test the diagnostic accuracy of the horizontal head impulse test (h-HIT) of vestibulo-ocular reflex (VOR) function in distinguishing acute peripheral vestibulopathy (APV) from stroke. Most patients with acute vertigo, nausea/vomiting, and unsteady gait have benign APV (vestibular neuritis or labyrinthitis) as a cause. However, some harbor life-threatening brainstem or cerebellar strokes that mimic APV. A positive h-HIT (abnormal VOR) is said to predict APV.
Methods: Cross-sectional study at an urban, academic hospital over 6 years. Consecutive acute vestibular syndrome patients at high risk for stroke underwent structured examination (including h-HIT), neuroimaging, and admission. Stroke was confirmed by neuroimaging (MRI or CT). APV was diagnosed by normal MRI and appropriate clinical evolution in follow-up.
Results: Forty-three subjects enrolled. One had an equivocal h-HIT. Patients with APV had a positive h-HIT (n = 8/8, 100%). Most patients with stroke had a negative h-HIT (n = 31/34, 91%). However, contrary to conventional wisdom, three patients with stroke (9%) demonstrated a positive h-HIT (1 vestibulocerebellar, 1 pontocerebellar, 1 pontocerebello-labyrinthine stroke).
Conclusions: Patients with lateral pontine and cerebellar strokes can have a positive horizontal head impulse test (h-HIT), so the sign’s presence cannot be solely relied upon to identify a benign pathology. Additional clinical features (e.g., directionality of nystagmus, severity of truncal instability, nature of hearing loss) must be considered in patients with acute vestibular syndrome with a positive h-HIT before a central localization can be confidently excluded. Nonetheless, the h-HIT remains a useful bedside test—in acute vestibular syndrome patients, a negative h-HIT (i.e., normal VOR) strongly suggests a central lesion with a pseudo-labyrinthine presentation.
Glossary
- APV=
- acute peripheral vestibulopathy;
- DWI=
- diffusion-weighted imaging;
- FLAIR=
- fluid-attenuated inversion recovery;
- h-HIT=
- horizontal head impulse test;
- VOR=
- vestibulo-ocular reflex.
AAN Members
We have changed the login procedure to improve access between AAN.com and the Neurology journals. If you are experiencing issues, please log out of AAN.com and clear history and cookies. (For instructions by browser, please click the instruction pages below). After clearing, choose preferred Journal and select login for AAN Members. You will be redirected to a login page where you can log in with your AAN ID number and password. When you are returned to the Journal, your name should appear at the top right of the page.
AAN Non-Member Subscribers
Purchase access
For assistance, please contact:
AAN Members (800) 879-1960 or (612) 928-6000 (International)
Non-AAN Member subscribers (800) 638-3030 or (301) 223-2300 option 3, select 1 (international)
Sign Up
Information on how to subscribe to Neurology and Neurology: Clinical Practice can be found here
Purchase
Individual access to articles is available through the Add to Cart option on the article page. Access for 1 day (from the computer you are currently using) is US$ 39.00. Pay-per-view content is for the use of the payee only, and content may not be further distributed by print or electronic means. The payee may view, download, and/or print the article for his/her personal, scholarly, research, and educational use. Distributing copies (electronic or otherwise) of the article is not allowed.
Letters: Rapid online correspondence
REQUIREMENTS
You must ensure that your Disclosures have been updated within the previous six months. Please go to our Submission Site to add or update your Disclosure information.
Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment.
If you are responding to a comment that was written about an article you originally authored:
You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid
and apply to letter.
Submission specifications:
- Submissions must be < 200 words with < 5 references. Reference 1 must be the article on which you are commenting.
- Submissions should not have more than 5 authors. (Exception: original author replies can include all original authors of the article)
- Submit only on articles published within 6 months of issue date.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- Submitted comments are subject to editing and editor review prior to posting.
You May Also be Interested in
Dr. Dennis Bourdette and Dr. Lindsey Wooliscroft
► Watch
Alert Me
Recommended articles
-
Views & Reviews
Recent advances in head impulse test findings in central vestibular disordersJeong-Yoon Choi, Hyo-Jung Kim, Ji-Soo Kim et al.Neurology, February 28, 2018 -
Resident and Fellow Section
Clinical Reasoning: A 55-year-old woman with vertigoA dizzying conundrumDaniel R. Gold, Stephen G. Reich et al.Neurology, October 22, 2012 -
Article
Head impulse gain and saccade analysis in pontine-cerebellar stroke and vestibular neuritisLuke Chen, Michael Todd, Gabor M. Halmagyi et al.Neurology, September 24, 2014 -
Article
Vestibular neuritis affects both superior and inferior vestibular nervesRachael L. Taylor, Leigh A. McGarvie, Nicole Reid et al.Neurology, September 30, 2016