何时对头晕患者使用HINTS检查：一篇综述

文献信息

中文摘要

重要性： 头脉冲试验、眼震、偏斜试验（HINTS）检查是一种广泛认可的床旁工具，用于在表现为急性前庭综合征的患者中区分外周前庭疾病与中枢性病因（如卒中）。然而，尽管该检查于2009年提出，关于其正确应用仍存在困惑。HINTS检查的误用，尤其是将其应用于不合适的患者人群时，可能导致误诊、不必要的影像学检查或漏诊卒中。本综述旨在阐明HINTS检查的适当使用，并解决导致急诊和临床实践中诊断错误的误解。
观察： HINTS在用于存在持续性头晕且静息时有自发性眼震的患者时最为有效。然而，各种指南和教育资源未能清晰界定这些标准，导致该检查被广泛误用。常见错误包括对无眼震的患者使用HINTS、在进行检查前未筛查中枢性特征，以及错误解读检查组成部分。研究表明，HINTS检查在正确应用时对检测卒中具有高敏感性，但当用于不合适的患者时，其诊断准确性显著下降。此外，近期指南，如第三版《急诊科合理和适当护理指南》（GRACE-3），可能引入了模糊之处，可能助长了临床实践中持续存在的困惑。
结论与意义： 为优化HINTS检查的诊断效用并减少卒中误诊，临床医生应先筛查中枢性特征，然后再应用HINTS，并确保仅对静息时有眼震的患者进行该检查。未来指南应提供更清晰的建议，以防止不适当的HINTS使用，从而避免不准确的结果。强调在正确患者人群中正确应用HINTS将增强其作为急诊医生区分头晕中枢性与外周性病因的关键工具的可靠性，最终改善患者结局并减少不必要的检查。

英文摘要

IMPORTANCE: The Head Impulse, Nystagmus, Test of Skew (HINTS) examination is a widely recognized bedside tool for distinguishing peripheral vestibular disorders from central causes, such as stroke, in patients presenting with acute vestibular syndrome. However, despite its introduction in 2009, confusion persists regarding its proper application. Misuse of the HINTS examination, particularly when applied to inappropriate patient populations, may lead to misdiagnosis, unnecessary imaging, or missed strokes. This review aims to clarify the appropriate use of the HINTS examination and to address misconceptions that contribute to diagnostic errors in emergency and clinical practice.
OBSERVATIONS: HINTS is most effective when performed for patients with continuous dizziness and spontaneous nystagmus at rest. However, various guidelines and educational resources have failed to clearly define these criteria, leading to widespread misapplication of the test. Common errors include using HINTS for patients without nystagmus, failing to screen for central features before performing the examination, and misinterpreting test components. Studies show that the HINTS examination, when applied correctly, has high sensitivity for detecting stroke, but its diagnostic accuracy declines significantly when used for inappropriate patients. Furthermore, recent guidelines, such as the third Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-3), may have introduced ambiguities that may contribute to ongoing confusion in clinical practice.
CONCLUSIONS AND RELEVANCE: To optimize the diagnostic utility of the HINTS examination and reduce stroke misdiagnosis, clinicians should first screen for central features before applying HINTS and ensure it is only performed for patients with nystagmus at rest. Future guidelines should provide clearer recommendations to prevent inappropriate HINTS use and thus avoid inaccurate results. Emphasizing the correct application of HINTS in the right patient population will enhance its reliability as a critical tool for emergency physicians in distinguishing central from peripheral causes of dizziness, ultimately improving patient outcomes and reducing unnecessary investigations.