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Head Up, Head Down in Stroke Doesn’t Matter

August 29, 2017

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Supine position to improve cerebral blood flow in ischemic stroke patients did not impact outcome positively or negatively compared to head-of-bed elevation 30 degrees.

Why does this matter?
There is ambiguity about the best head position in stroke.  Some patients are positioned with the head of the bed elevated 30 degrees to decrease the risk of aspiration or decrease ICP in large hemispheric stroke.  Small RCTs have shown supine position may improve cerebral blood flow and could reduce the ischemic penumbra.  This study provided a definitive answer – head position doesn’t help or harm stroke patients.

Heads up, heads down, doesn’t matter
This was a cluster randomized crossover trial in over 11,000 stroke patients in nine countries, 85% of which were ischemic.  Head position supine, horizontal with face up vs. 30 degrees elevation of the head was initiated and maintained for 24 hours. Average time from stroke onset to head position was 14 hours; 7 hours from hospital arrival to head position assignment.  There was no improvement in functional outcome at 90 days with supine head position, nor was there harm, such as increased aspiration pneumonia risk.  Maybe the outcome would have changed had head position been started earlier than 7 hours into the patient’s hospital course.

Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke.  N Engl J Med. 2017 Jun 22;376(25):2437-2447. doi: 10.1056/NEJMoa1615715.

Peer reviewed by Thomas Davis, MD.

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