C.S. Anderson, H. Arima and P. Lavados et el published in NEJM a new cluster randomized trial about head position in acute ischemic stroke showing no difference between head elevation and flat position for first 24 hours (HeadPost Trial).
Earlier animal and non randomized small human studies showed that flat position may increase the blood flow to the brain on affected side. Therefore, a flat position was recommended to improve the blood flow. Elevation of head of bed have been used to reduce ventilator associated pneumonias and has been part of several bundles to improve outcome in intensive care patients. By proxy, it has been used in patients who are not mechanically ventilated.
Compared flat bed with head of bed elevation to at least 30 degrees. 5295 patients were treated flat, and 5799 were treated with head of bed elevation in 116 hospitals in 9 countries.
Primary outcome was disability at 90 days, Secondary outcomes included death or major disability (modified Rankin scale scores of 3 to 6) at 90 days, death within 90 days
after stroke, duration of hospital stay, the individual components of the EQ-5D at 90 days, the
distribution of levels across the modified Rankin scale at 7 days, and the distribution of seven
levels of increasing neurologic impairment according to categorical scores on the NIHSS or
death at 7 days.
There were no significant difference in the above mentioned outcomes.
We can use either position to treat acute ischemic stroke, depending on the other co-morbidities.