Purpose <p>Head-Impulse, Nystagmus, Test-of-Skew (HINTS) testing is recommended to identify stroke in the acute vestibular syndrome (AVS). 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 (“HINTS+”) to improve sensitivity for AICA-stroke detection.</p> Methods <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.</p> Results <p>We identified 4388 citations and included 11 articles (<i>n</i> = 770 patients). Ischemic strokes (<i>n</i> = 319) and acute unilateral vestibulopathy (<i>n</i> = 391) were the most frequent causes. AUHL was most often assessed by finger rub (<i>n</i> = 311), tuning-fork tests (<i>n</i> = 114), or whispered words (<i>n</i> = 169), and was present in 50 patients (central = 29, peripheral = 21). 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 = 92.7% [88.7–96.8%]; specificity = 91.1% [86.3–95.8%]) was high. Adding AUHL (HINTS+) increased sensitivity (95.7% [92.7–98.7%]) but decreased specificity (80.7% [70.6–90.7%]), though the latter was largely from bias in patient selection. AUHL had the biggest impact for AICA-territory strokes, increasing sensitivity from 73.3% (59.0–84.0%) to 91.1% (79.3–96.5%).</p> Conclusions <p>Testing for AUHL in AVS increased stroke-sensitivity, but this effect was mainly related to AICA-strokes with abnormal head-impulse testing (<i>n</i> = 19/22), 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).</p>