Diagnostic accuracy of HINTS Plus test in the differential diagnosis of central and peripheral vertigo: a prospective, cross-sectional study

BACKGROUND: We evaluated the diagnostic accuracy of the HINTS Plus tool in differentiating central vertigo from peripheral vertigo in the emergency department, using neuroimaging as the reference standard. METHODS: This cross-sectional study included adult patients with acute vestibular syndrome without focal neurological deficits. Crucially, all patients underwent neuroimaging with non-contrast brain tomography and magnetic resonance imaging to definitively exclude central pathology. Diagnostic accuracy of the HINTS Plus test was assessed by comparing bedside findings with neuroimaging results. RESULTS: Of 298 patients enrolled, 62 had central and 236 peripheral vertigo patients. The sensitivity and specificity of the HINTS Plus for detecting central vertigo were 80.65% (95% CI: 68.63-89.58) and 82.63% (95% CI: 77.18-87.24), respectively. The Head Impulse Test demonstrated the highest sensitivity (70.97%) among individual components. CONCLUSION: HINTS Plus demonstrated moderate diagnostic accuracy in a real-world emergency department setting. Although useful as a bedside adjunct, the observed false-negative rate and LR- suggest that HINTS Plus should not be used as the sole strategy to exclude central causes of acute vestibular syndrome. Neuroimaging and overall clinical assessment remain essential components of diagnostic decision-making.