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Title: Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke
Authors: Anderson, Craig S.
Arima, Hisatomi
Lavados, Pablo
Billot, Laurent
Hackett, Maree L.
Olavarría, Veronica V.
Muñoz Venturelli, Paula
Brunser, Alejandro
Peng, Bin
Cui, Liying
Song, Lily
Rogers, Kris
Middleton, Sandy
Lim, Joyce Y.
Forshaw, Denise
Lightbody, C. Elizabeth
Woodward, Mark
Pontes-Neto, Octavio
De Silva, H. Asita
Lin, Ruey-Tay
Lee, Tsong-Hai
Pandian, Jeyaraj D.
Mead, Gillian E.
Robinson, Thompson
Watkins, Caroline
HeadPoST Investigators and Coordinators
First Published: 22-Jun-2017
Publisher: Massachusetts Medical Society
Citation: The New England Journal of Medicine, 376 (25), pp. 2437-2447
Abstract: BACKGROUND: The role of supine positioning after acute stroke in improving cerebral blood flow and the countervailing risk of aspiration pneumonia have led to variation in head positioning in clinical practice. We wanted to determine whether outcomes in patients with acute ischemic stroke could be improved by positioning the patient to be lying flat (i.e., fully supine with the back horizontal and the face upwards) during treatment to increase cerebral perfusion. METHODS: In a pragmatic, cluster-randomized, crossover trial conducted in nine countries, we assigned 11,093 patients with acute stroke (85% of the strokes were ischemic) to receive care in either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees, according to the randomization assignment of the hospital to which they were admitted; the designated position was initiated soon after hospital admission and was maintained for 24 hours. The primary outcome was degree of disability at 90 days, as assessed with the use of the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability and a score of 6 indicating death). RESULTS: The median interval between the onset of stroke symptoms and the initiation of the assigned position was 14 hours (interquartile range, 5 to 35). Patients in the lying-flat group were less likely than patients in the sitting-up group to maintain the position for 24 hours (87% vs. 95%, P<0.001). In a proportional-odds model, there was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the lying-flat group and patients in the sitting-up group (unadjusted odds ratio for a difference in the distribution of scores on the modified Rankin scale in the lying-flat group, 1.01; 95% confidence interval, 0.92 to 1.10; P=0.84). Mortality within 90 days was 7.3% among the patients in the lying-flat group and 7.4% among the patients in the sitting-up group (P=0.83). There were no significant between-group differences in the rates of serious adverse events, including pneumonia. CONCLUSIONS: Disability outcomes after acute stroke did not differ significantly between patients assigned to a lying-flat position for 24 hours and patients assigned to a sitting-up position with the head elevated to at least 30 degrees for 24 hours. (Funded by the National Health and Medical Research Council of Australia; HeadPoST number, NCT02162017).
DOI Link: 10.1056/NEJMoa1615715
ISSN: 0028-4793
eISSN: 1533-4406
Version: Publisher Version
Status: Peer-reviewed
Type: Journal Article
Rights: Copyright © 2017, Massachusetts Medical Society. Deposited with reference to the publisher’s open access archiving policy.
Description: The file associated with this record is under embargo until 6 months after publication, in accordance with the publisher's self-archiving policy. The full text may be available through the publisher links provided above.
Appears in Collections:Published Articles, Dept. of Cardiovascular Sciences

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