Application of bedside HINTS, ABCD2score and truncal ataxia to differentiate cerebellar–brainstem stroke from vestibular neuritis in the emergency room

Background and purpose Acute vestibular syndrome (AVS) typically manifests as isolated dizziness or vertigo with no apparent neurological impairments. However, distinguishing life-threatening stroke from innocuous peripheral vestibular lesions in the emergency room (ER) remains challenging. This study aimed to explore the ability of the head impulse-nystagmus-test of skew (HINTS) combined with truncal ataxia or ABCD 2 score to differentiate stroke from peripheral vestibular disease in patients with AVS in the ER. Methods We prospectively recruited 121 patients with AVS from December 2022 to June 2023, 69 of whom presented with vestibular neuritis (VN) and the remaining with posterior circulation stroke (PCS). We analysed the HINTS results, truncal ataxia and ABCD 2 score and compared the sensitivity and specificity among HINTS, truncal ataxia, ABCD 2 score and their combinations using the McNemar test for paired samples. Results HINTS combined with grade 2-3 truncal ataxia achieved significantly higher sensitivity than that of isolated HINTS in differentiating PCS from VN (100% vs 88.5%, p=0.031). The specificity of HINTS plus grade 2-3 truncal ataxia did not significantly differ from that of isolated HINTS (p=0.125); however, the combination of ABCD 2 score and HINTS did not improve the diagnostic accuracy. The sensitivity of ABCD 2 score ≥4 plus grade 2-3 truncal ataxia was significantly higher than those of isolated ABCD 2 score ≥4 or isolated grade 2-3 truncal ataxia (p=0.016 and p<0.001, respectively) and not significantly lower than that of isolated HINTS (p=0.508). Conclusion Compared with the ABCD 2 score, the truncal ataxia is of more valuable assistance to HINTS in differentiating PCS. Although the combination of ABCD 2 score and truncal ataxia has a significant implication, it is not a replacement for HINTS.