The role of the HINTS exam, TriAGe+ score, and ABCD2 score in predicting stroke in acute vertigo patients in the ED

Abstract

Objective

Posterior circulation stroke can mimic benign causes of vertigo, presenting with no obvious neurologic signs. Differentiating central from peripheral causes remains a challenge. We aimed to compare the diagnostic accuracy of three bedside screening tools for cerebrovascular causes of vertigo: HINTS examination, ABCD2 score, and TriAGe+ score.

Method

We conducted a single-center, prospective, observational study. Our primary outcome was to determine the diagnostic accuracy of the HINTS exam, ABCD2 score, and TriAGe+ score for predicting stroke in patients presenting with isolated dizziness or vertigo. Receiver operating characteristic (ROC) curve analysis was performed to determine the best cut-off scores.

Results

357 patients were recruited, of which 58 were diagnosed with stroke. The sensitivity and specificity of the HINTS exam were 100% and 85.9%, respectively. At a cut-off ≥ 10 for the TriAGe+ score, a sensitivity of 46.6% and a specificity of 96.3% was found. The sensitivity and specificity of the ABCD2 score (≥4) were 65.5% and 68.6%. AUC values for HINTS, ABCD2, and TriAGe+ scores were 0.88, 0.71, and 0.88, respectively. The TriAGe+ score and HINTS exam showed the same diagnostic performance. The exclusion power of the HINTS exam was higher due to the negative LR of 0.0, whereas the diagnostic power of the TriAGe+ score was higher due to the positive LR of 12.65.

Conclusion

The diagnostic accuracy of the HINTS exam and the TriAGE+ score was better than the ABCD2 score. In our cohort, the HINTS exam was highly sensitive, whereas the specificity of the TriAGe+ score was better than other tests. Clinical experience and training are essential for a reliable HINTS exam, whereas the TriAGe+ score, with its practical structure, could help clinicians identify stroke in the chaotic ED environment.