- Written by Ethan Abbott
A 75 yo male with a PMH of HTN, HLD, DM, and PVD presents to the SBH emergency department with slurred speech and right sided weakness x 2 hours. He is awake and alert on arrival with a glucose of 122. The patient undergoes a non-contrast CT of the brain which is unremarkable. In consultation with neurology, tPA is administered and the patient is admitted to the hospital. While awaiting his transfer to the floor, you insure the patient’s head of bed is at 30 degrees, as this is considered the “standard of care.” Can a patient be positioned supine after an acute ischemic stroke?
Answer: The “head of bed elevated” theory is that patients would benefit from “reduced intracranial pressure” and “decreased risk for aspiration” if the head was elevated after an acute ischemic CVA. Recent, small, non-randomized trials of patients positioned supine after an acute ischemic stroke have called this practice of “head elevated” after ischemic stroke into question. These newer trials suggest that supine positioning “increases blood flow in major arteries and improves oxygenation of the brain.” A large trial in the NEJM published last month attempts to address this issue.
In the the Head Positioning in Acute Stroke Trial (HeadPoST)trial, published in the NEJM in June of 2017, the authors examined the question of whether this head positioning, either lying flat or head elevated for 24 hours after an acute ischemic or hemorrhagic stroke, in a variety of clinical settings, including the emergency department, had an effect. The study design was an international, multicenter, cluster-randomized, crossover, open-label trial with blinded outcome evaluation. The primary outcome of the study was disability at 90 days and secondary outcomes of death and disability using a modified Rankin scale. The study is powered by 11,093 patients in 114 centers (however ended up underpowered). Patients were randomized to either group and were required to maintain positioning for 24 hours. The authors found, “ no significant difference between the implementation — at a median of 14 hours after the onset of stroke — of the lying-flat head position and the sitting-up position with respect to the primary outcome of level of disability at 90 days. There were also no significant differences in mortality or in the rates of serious adverse events, including pneumonia.”
There are some potentially controversial issues regarding the data (did not reach sample size) and methodology (pragmatic cluster clinical trial), so take a look at the article and draw your own conclusions!
Anderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, Muñoz Venturelli P, Brunser A, Peng B, Cui L, Song L, Rogers K, Middleton S, Lim JY, Forshaw D, Lightbody CE, Woodward M, Pontes-Neto O, De Silva HA, Lin RT, Lee TH, Pandian JD, Mead GE, Robinson T, Watkins C; HeadPoST Investigators and Coordinators. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017 Jun 22;376(25):2437-2447.