Training in VNG

Skew Deviation in HINTS Protocol: Next Step?

10 mins
09 February 2022


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.

Learning Objectives


A photo of Dr. João Lemos
Dr. João Lemos
Dr. João Lemos, Neurologist and Neuro-Ophthalmologist, has worked in the field of oculomotor testing in neurological patients for 15 years, both as a clinician and researcher. He is based at Coimbra University Hospital Centre, Coimbra, Portugal. Dr. Lemos is the Director of the Neurology of Vision and Balance Unit in the hospital’s Neurology Department, which sees around 1500 neuro-ophthalmological and neuro-otological patients annually. 

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