Intended for healthcare professionals

Practice Easily Missed?

Posterior circulation ischaemic stroke

BMJ 2018; 361 doi: (Published 19 April 2018) Cite this as: BMJ 2018;361:k1185

Re: Posterior circulation ischaemic stroke

The finding that the HINTS exam has a sensitivity of 100% in detecting posterior circulation stroke as reported in the study cited in this article have never been validated in larger studies.(1)

The HINTS exam has a sensitivity of 88% in one study from Spain.(2) We have seen cases of proven cerebellar stroke and negative HINTS exam, with DWI images revealing small cerebellar infarcts. We don’t believe that the reason the HINTS exams were negative in these cases was because they were not performed properly.

We recommend not ruling out a diagnosis of posterior circulation stroke on the basis of findings in one single study of 101 patients from one single center.


1-Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedsideoculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10. doi: 10.1161/STROKEAHA.109.551234. Epub 2009 Sep 17.

2-Batuecas-Caletrío Á, Yáñez-González R, Sánchez-Blanco C, et al. Peripheral vertigo versus central vertigo. Application of the HINTS protocol]. Rev Neurol. 2014 Oct 16;59(8):349-53.

Competing interests: No competing interests

26 April 2018
Hussam Ammar
Attending Physician
Shaunak P Kulkarni, Rukma R. Govindu, MD
MedStar Washington Hospital Center
MedStar Washington Hospital Center . 110 Irving St NW, Washington, DC 20010