When a patient presents with acute vestibular syndrome (AVS), the primary responsibility of the examiner is to determine, as best as possible, whether this represents a worrisome pathology such as a posterior fossa stroke. While the vast majority of patients presenting with AVS will ultimately be found to have peripheral vestibular disorders, this does not undermine the importance of performing fast and efficient screenings to determine which patients might be at high risk for stroke and require neuroimaging.
Most of these patients present to the emergency department (ED). Historically, the ED exam involves immediate imaging, primarily CT scan and occasionally MRI, with the goal of identifying or ruling out stroke as a source of the patient’s acute vertigo symptoms. This protocol has been questioned, and the Society for Academic Emergency Medicine released a practice guideline in 2023 known as GRACE 3 (Guideline for Reasonable and Appropriate Care in the Emergency Department), which we covered in a previous HHTM article here.
This document is detailed, accurate, and unequivocal about the role of imaging in the evaluation of AVS. In fact, out of 15 recommendations from the guideline, three recommend against the use of CT scanning.
With high to moderate certainty of evidence, they recommend against the use of CT scanning for AVS, recommend against the use of CT scanning for spontaneous episodic dizziness, and recommend against the use of CT scanning for triggered episodic dizziness.1
The GRACE 3 guidelines advocate for the use of bedside testing, including the HINTS protocol for AVS and the Dix-Hallpike test for triggered vertigo. The first of the 15 recommendations is essentially, “Emergency clinicians should be trained in the HINTS protocol,” with another recommendation essentially stating, “If you don’t know how to do the HINTS exam, find someone who does.”
Two logical follow-up questions are:
- Are emergency department physicians adopting this guideline?
- Since the release of the GRACE 3 guidelines in May 2023, is there any additional information that supports or disputes the guideline recommendations?
What Has Changed Since the GRACE 3 Guidelines?
A review of the literature released after May 2023, when the GRACE 3 guideline was released, reveals some disturbing trends. A United States study published in 2025 in the American Journal of Emergency Medicine reports that 71% of HINTS exams performed in the emergency department are performed on inappropriate patients.
The most common error was that the exam is often performed on patients with no spontaneous nystagmus, and the authors expressed concern over “a lack of understanding of interpretation of the exam.”2
In a 2025 study out of Saudi Arabia:
“43.6% of the emergency physicians in Saudi Arabia showed strong familiarity with the HINTS examination. However, many expressed uncertainty about its sensitivity compared to MRI for diagnosing AVS and its suitability for all vertigo patients. Most participants observed vertigo cases needing the HINTS examination, but many reported that ED colleagues seldom performed the test, and only seven (6.9%) felt confident conducting it. While over half felt undertrained, 80 (79.2%) advocated for teaching the HINTS examination to ED trainees. ED and consulting services were perceived as underutilizing the exam, highlighting a need for further education.”3
A recent 2024 survey of emergency department residency program directors in the United States demonstrates that the majority (78%) believe the HINTS exam is valuable to teach, but 63% expressed concern regarding the faculty expertise required to teach it.4
While it appears that ED physicians acknowledge the benefits of performing HINTS when examining a patient with acute vertigo, and the Society for Academic Emergency Medicine (SAEM) has produced a strong guideline, adoption and understanding remain low.
Why Bedside Testing Matters
Why is the transition from relying on imaging to understanding when and how to perform the HINTS exam important?
Historically, physicians have relied on imaging to determine whether a patient with acute vertigo may be suffering a posterior fossa stroke. CT scan is ordered on between 25% and 50% of patients presenting to the ED for dizziness.6,7 A recent 2025 review of imaging performed on patients in the ED for vertigo found that 95% are interpreted as normal, 2% yielded actionable findings, and 1.2% “revealed acute central causes contributing to vertigo.”8
A retrospective review in 2023 reports that, of 85 patients with confirmed by MRI posterior fossa stroke, stroke was detected in only 27% of those undergoing emergent cranial CT scan. In this study, stroke was identified by the HINTS exam with 100% sensitivity. A 2014 study out of Johns Hopkins estimates that over one billion dollars a year is spent on unnecessary imaging, with that number likely rising with reports of increased utilization.9
“CT scanning for acute vertigo is expensive, low yield, has poor sensitivity, and can be falsely reassuring. A properly performed HINTS exam is between 96% and 100% sensitive in identifying patients who require neuroimaging.”
Take-Home Message
CT scanning for acute vertigo is expensive, low yield, has poor sensitivity, and can be falsely reassuring. A properly performed HINTS exam is between 96% and 100% sensitive in identifying patients who require neuroimaging. These facts are the core of the SAEM GRACE 3 guideline. Acceptance and adoption of the guideline recommendations are a work in progress.
References
- Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3): Acute Dizziness and Vertigo in the Emergency Department – PubMed
- Improper Performance of HINTS Exam in Emergency Physicians Is Driven by Incorrect Use of Nystagmus – PubMed
- Knowledge, Attitude, and Practice of the Head Impulse, Nystagmus, and Test of Skew (HINTS) Examination Among Emergency Physicians in Saudi Arabia: A Cross-Sectional Study – PMC
- Leadership Perceptions, Educational Struggles and Barriers, and Effective Modalities for Teaching Vertigo and the HINTS Exam: A National Survey of Emergency Medicine Residency Program Directors – PubMed
- Low Incidence of Acute Actionable Imaging Findings in Emergency Department Patients Imaged for Vertigo: Retrospective Analysis and Proposed Guidelines – PubMed
- Imaging for Nonspecific Dizziness in the Emergency Department Is Associated With Delayed Time to First Otolaryngology Evaluation – PubMed
- Stroke Risk After Non-Stroke ED Dizziness Presentations: A Population-Based Cohort Study – PMC
- Dizziness Evaluation and Characterisation of Patients with Posterior Circulation Stroke in the Emergency Department: A Case Series Study – PubMed
- Keita et al. Diagnostic Errors, Harms, and Waste in Evaluating Dizziness and Vertigo in Ambulatory Settings Across the United States. Johns Hopkins University School of Medicine.
About the author
Alan Desmond, AuD, is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. He has written several books and book chapters on balance disorders and vestibular function. He is the co-author of the Clinical Practice Guideline for Benign Paroxysmal Positional Vertigo (BPPV). In 2015, he was the recipient of the President’s Award from the American Academy of Audiology.
