In Stroke, No Clear Benefit for Head Positioning
Previous research has indicated possible risks and benefits associated with head position in acute stroke.
Specific head positioning — either lying flat or sitting up — appears to have no or little benefit for outcomes in patients with acute stroke. Results of the Head Position in Acute Stroke Trial (HeadPoST)1 were presented at the 2017 International Stroke Conference, February 22-24, 2017 in Houston, Texas.
While previous data suggested that head position could have a positive impact in acute stroke, specifically increasing blood flow to the brain or reducing cerebral edema,1 studies examining the effects have been small and non-randomized. In addition, lying flat has been associated with adverse outcomes in this population, including the development of pneumonia or respiratory distress. Clinical practice varies, with the American Stroke Association guidelines2 ultimately stating that the ideal position is unknown, and that clinicians must take into consideration “competing interests, as well as patient tolerance.”
In an effort to better understand the risks and benefits of lying flat vs sitting up (≥30 degrees) on 24-hour and 90-day outcomes in patients with acute stroke, Professor Craig S. Anderson, MD, PhD, of the George Institute for Global Health and the University of Sydney, Australia, and colleagues conducted a large, international, multicenter, randomized, crossover trial that included more than 11,000 patients (mean age, 68 years; 60% male) from 114 hospitals.
Patients, of whom 91% presented with acute ischemic stroke, were randomly assigned to spend 20 to 24 hours either lying flat (n = 5298) or sitting-up (n = 5798). Ultimately, 13% of the patients who were lying flat and 4% of the patients sitting up discontinued the intervention, citing issues with position tolerance, compliance, patient/doctor preference, or a change in medical condition.
At 90-day follow-up, 48.2% of the patients assigned to the sitting-up position and 47.7% of the patients assigned to the lying flat position had a modified Rankin Scale (mRS) score of 2 to 6, indicating death or disability (odds ratio[OR], 1.01; 95% CI 0.92-1.10; P =.84). Dependency or death (mRS 3-6) at 90-days occurred in 29% of the lying-down group and 40% of the sitting-up group, with death occurring in 7% of patients in both groups at 90-day follow-up.
Overall, head position had no effect on disability outcomes in either group and, of note, no serious adverse outcomes were recorded in either position. When analyzed by subgroups according to time to treatment, stroke severity, age, region, or acute ischemic vs hemorrhagic stroke, no clear benefits or harms were evident for either head position.
The findings ultimately call into question the utility of head positioning in acute stroke and suggest that a review of current clinical practice guidelines is warranted.
Disclosures: Dr Anderson reports receiving speaker fees and reimbursement for travel expenses from Takeda China and Boehringer Ingelheim, as well as grant support from the National Health and Medical Research Council of Australia.
- Anderson CS; for the HeadPoST Steering Committee, Investigators, and Coordinators. Head position in stroke trial: An international cluster cross-over randomized trial. Presented at: 2017 International Stroke Conference. February 22-24, 2017; Houston, TX.
- Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.