BY ED SUSMAN
HOUSTON—In a large international study, researchers determined that positioning a patient sitting up in bed or lying flat after a mild stroke doesn't appear to have an effect on recovery, researchers reported here Wednesday at the International Stroke Conference sponsored by the American Heart Association/American Stroke Association.
Clinicians have been uncertain about the optimal head position for recovery from acute ischemic stroke or intracerebral hemorrhage (ICH), the researchers noted. The potential benefits of lying flat in acute ischemic stroke (increased collateral blood flow) may be offset by increased risks of aspiration pneumonia and cardiac-respiratory impairment, they wrote in their abstract, adding that sitting up may reduce cerebral edema in ICH.
In the HEADPoST (Head Position in Stroke Trial), more than 11,000 patients — across 114 hospitals in Australia, Brazil, Chile, China, Columbia, India, Sri Lanka, Taiwan, and the United Kingdom — were treated between 2014 and 2016 while lying down or sitting up. Fifty-one percent of the patients had been diagnosed with hypertension, 24 percent had had a prior stroke, and the median NIH Stroke Scale (NIHSS) score was 4 (indicating moderate stroke) in both groups.
The outcomes were found to be almost identical on multiple measures, including cases of pneumonia caused by aspiration, reported Craig Anderson, MD, PhD, professor of stroke medicine and clinical neuroscience at George Institute of Global Health in Sydney, Australia.
"We found no clear benefit or harm with specific head positioning in acute stroke," Dr. Anderson said.
"We also found no difference in outcomes if the patients were diagnosed with an acute ischemic stroke or with an ICH," he said. Similarly, the researchers were unable to find an advantage for one method or the other when patients were stratified by age, by country where the intervention was performed, by the baseline NIHSS score, or by type of acute stroke and time to treatment.
Among outcomes, after 90 days, the percent of patients achieving a modified Rankin Scale Score of 0 (indicating no symptoms) was 18.2 percent among the patients who were allowed to sit up after their stroke compared with 15.9 percent of those who were lying flat. In addition, 16.2 percent of patients who were assigned to sitting up were diagnosed with a modified Rankin Scale score of 3 (indicating moderate disability) compared with 15.2 percent of patients who were told to lie flat.
Dr. Anderson said one of the strengths of the trial was that it could be implemented globally. He pointed out that it was one of the largest to test the new clustering technique in which the patients were randomized by institution and conducted mainly by utilizing the hospitals' nursing management staff. A hospital would treat one group of 70 patients in a cluster of either lying flat or sitting up and then the next group of patients would be switched.
Commenting on the results, Bruce I. Ovbiagele, MD, FAAN, chair of the conference and chief of neurology at the Medical University of South Carolina in Charleston, said: "Since there was no difference [in outcomes], and patients seemed to feel better sitting up, I would likely have my patients sit up. This study may have had neutral results because these were mild strokes for the most part, and when you have an average NIHSS score of 4 there is not that much room to show a difference in improvement."
Dr. Ovbiagele suggested that a study conducted among patients with larger, more serious strokes might show differences in outcomes.
The trial was sponsored by the National Health and Medical Research Council of Australia, Takeda China, and Boehringer Ingelheim.
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