Clinical picture

Sudden-onset, prolonged vertigo with horizontal-torsional nystagmus, head-motion intolerance, nausea, and gait unsteadiness. Hearing is spared (distinguishing it from labyrinthitis). Symptoms peak in 24 hours and improve over days to weeks as central compensation develops¹¹.

HINTS signature — peripheral pattern

Head Impulse: abnormal toward the affected side (corrective saccade)
Nystagmus: unidirectional, horizontal-torsional, fast phase away from the affected ear
Skew: absent

This is the reassuring triad. When complete and unambiguous in a patient with acute vestibular syndrome, HINTS is consistent with a peripheral cause — but the clinical context matters^3,10.

Head velocity Eye velocity Corrective saccade

VOR gain: 0.40 · abnormal — corrective saccade present (peripheral pattern)

VOR gain0.40

Peak head velocity200°/s

Drag the gain slider below 0.8 to produce the corrective saccade — the positive head-impulse finding. Bedside HINTS detects this saccade visually; vHIT measures it on a velocity trace like the one above.

Trainee

Superior vs inferior vestibular neuritis

Superior vestibular neuritis is much more common and produces the classic findings above plus an abnormal oVEMP (utricular pathway) and normal cVEMP (saccular pathway preserved). Inferior vestibular neuritis is rarer, may produce posterior-canal head impulse findings, an abnormal cVEMP, and a normal oVEMP. The anatomical distinction matters for prognosis and for understanding the head-impulse findings on vertical canals.

Clinician

Mimics and caveats

The peripheral HINTS pattern does not exclude AICA stroke involving the labyrinthine artery — which can present with peripheral HINTS plus acute sensorineural hearing loss. This is the rationale for HINTS-plus^10,1. A patient with apparently classic vestibular neuritis but new hearing loss, persisting central symptoms, or vascular risk factors should have urgent posterior fossa imaging.