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Diagnostic accuracy depends on the vascular territory involved, with lower sensitivity for anterior-inferior cerebellar artery (AICA)- than posterior-inferior cerebellar artery (PICA)-territory strokes. Adding new-onset, acute unilateral hearing loss (AUHL) as a fourth central sign has been proposed (\u201cHINTS+\u201d) to improve sensitivity for AICA-stroke detection.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We performed a systematic search (MEDLINE, Embase) to identify studies reporting diagnostic accuracy of bedside examination in AVS patients, including the diagnostic impact of HINTS+. Results were stratified by stroke location.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We identified 4388 citations and included 11 articles (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009770 patients). Ischemic strokes (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009319) and acute unilateral vestibulopathy (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009391) were the most frequent causes. AUHL was most often assessed by finger rub (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009311), tuning-fork tests (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009114), or whispered words (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009169), and was present in 50 patients (central\u2009=\u200929, peripheral\u2009=\u200921). Bedside head-impulse testing was abnormal in 25\/29 central cases with AUHL, with 19\/25 cases demonstrating an AICA-stroke. Diagnostic accuracy of HINTS (sensitivity\u2009=\u200992.7% [88.7\u201396.8%]; specificity\u2009=\u200991.1% [86.3\u201395.8%]) was high. Adding AUHL (HINTS+) increased sensitivity (95.7% [92.7\u201398.7%]) but decreased specificity (80.7% [70.6\u201390.7%]), though the latter was largely from bias in patient selection. AUHL had the biggest impact for AICA-territory strokes, increasing sensitivity from 73.3% (59.0\u201384.0%) to 91.1% (79.3\u201396.5%).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      Testing for AUHL in AVS increased stroke-sensitivity, but this effect was mainly related to AICA-strokes with abnormal head-impulse testing (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200919\/22), where adding AUHL yielded an absolute increase of 17.8% in stroke-sensitivity. In AVS, AUHL should be assessed at the bedside (and ideally confirmed by audiometry).\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00415-026-13641-3","type":"journal-article","created":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T10:23:33Z","timestamp":1770719013000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["HINTS+\u2009to diagnose AICA stroke:\u00a0systematic review of the diagnostic impact of acute unilateral hearing loss in the acute vestibular syndrome"],"prefix":"10.1007","volume":"273","author":[{"given":"Gitanjali","family":"Anburajan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jorge","family":"Kattah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zheyu","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgios","family":"Mantokoudis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David E.","family":"Newman-Toker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6984-6958","authenticated-orcid":false,"given":"Alexander A.","family":"Tarnutzer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,10]]},"reference":[{"key":"13641_CR1","doi-asserted-by":"crossref","first-page":"765","DOI":"10.4065\/83.7.765","volume":"83","author":"DE Newman-Toker","year":"2008","unstructured":"Newman-Toker DE, Hsieh YH, Camargo CA Jr., Pelletier AJ, Butchy GT, Edlow JA (2008) Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. 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Zheyu Wang declares no conflict of interest. Georgios Mantokoudis declares no conflict of interest. Jorge Kattah declares no conflict of interest. David E. Newman-Toker conducts research related to the diagnosis of dizziness and stroke. He serves as the principal investigator for multiple grants and contracts on these topics, including the NIH-sponsored AVERT clinical trial (NIDCD U01 DC013778, ClinicalTrials.gov #NCT02483429). Johns Hopkins has been loaned research equipment (video-oculography [VOG] systems) by two companies for use in Dr. Newman-Toker\u2019s research; one of these companies has also provided funding for research on diagnostic algorithm development related to dizziness, inner ear diseases, and stroke. Dr. Newman-Toker has no other financial interest in these or any other companies. Dr. Newman-Toker is an inventor on a patent (US Patent #12,266,109) for smartphone-based stroke diagnosis in patients with dizziness. He gives frequent academic lectures on these topics and occasionally serves as a medico-legal consultant for both plaintiff and defense in cases related to dizziness, stroke, and diagnostic error. Alexander A. Tarnutzer has received consultant and \/ or speaker fees from Mitsubishi Tanabe Pharma, AstraZeneca, Teva Pharma, Neuraxpharma, Angelini Pharma and Schwabe Pharma.","order":1,"name":"Ethics","label":"Conflicts of interest","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Being a systematic review of the literature, no ethical approval or consent was necessary.","order":2,"name":"Ethics","label":"Ethical approval, consent","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"131"}}