Head positioning in suspected patients with acute stroke from prehospital to emergency department settings: a systematic review and meta‐analysis

Abstract

Aim This study aimed to clarify whether the lying‐flat position from prehospital to emergency department settings more effectively improves neurological outcomes of patients suspected with acute stroke over the sitting‐up position. Methods We searched PubMed, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for published randomized controlled trials until September 2019. The study population included patients suspected with acute stroke from prehospital to emergency department settings. We compared outcomes between the lying‐flat position and sitting‐up position groups. The critical outcome was the modified Rankin Scale score at 90 days, and important composite outcomes were 90‐day mortality, pneumonia recurrence, and recurrent ischemic stroke. The certainty of evidence of the outcome level was compared using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results In total, 881 studies were identified from the databases, and two randomized controlled trials were included in the analysis. The pooled risk ratio of 90‐day modified Rankin Scale score was not statistically significant (risk ratio 0.86; 95% confidence interval [CI] 0.56–1.32) between the lying‐flat position and sitting‐up position groups. When comparing the 90‐day mortality, pneumonia occurrence, and recurrent ischemic stroke, no significant differences were observed between the two groups. Risk ratio was 1.00 (95% CI 0.87–1.14), 0.90 (95% CI 0.74–1.11), and 0.81 (95% CI 0.14–4.64) for 90‐day mortality, pneumonia occurrence, and recurrent ischemic stroke, respectively. Conclusion This study suggests that the lying‐flat position is not more effective than the sitting‐up position in terms of 90‐day modified Rankin Scale score in patients suspected with acute stroke.

Effects of postoperative lateral positioning on outcomes of patients with subarachnoid hemorrhage

“…In this study, the blood gas analysis results were significantly higher in the intervention group from the 24 hours postoperatively, when the position of the patient showed its first effect. This finding is consistent with the literature 9,12,14,15 . In a study investigating the effect of postoperative lateral position on blood gas parameters in the surgical ICU setting, it was shown that the lateral position improved oxygenation 16 .…”

A randomized trial of Trendelenburg position for acute moderate ischemic stroke

“…There are several differences between the current study and prior studies. First, the head position at −20° was adopted in the current study, while a horizontal supine versus sitting position was utilized in prior studies 2 – 5 , 8 , 9 , 20 . In theory, HDP can enhance cerebral blood flow and increase cerebral perfusion compared with a supine or sitting position due to the force of gravity 22 .…”

“…To date, there is a paucity of effective neuroprotective treatments for acute ischemic stroke (AIS), other than reperfusion therapy such as intravenous thrombolysis and mechanical thrombectomy, which is limited by a strict therapeutic time window and requirement for a highly developed stroke system of care 1 . The effect of head position (lying-flat vs sitting-up position) as a nonpharmacological therapy on stroke has been investigated 2 – 5 , but the inconsistent results have led to current ambiguous guideline recommendations 1 – 6 . It is generally accepted that the supine position may increase blood flow and improve oxygenation 2 – 4 , 7 – 9 , but with potential risks such as increased intracranial pressure, cardiopulmonary dysfunction, and aspiration pneumonia 10 – 13 .…”

“…The effect of head position (lying-flat vs sitting-up position) as a nonpharmacological therapy on stroke has been investigated 2 – 5 , but the inconsistent results have led to current ambiguous guideline recommendations 1 – 6 . It is generally accepted that the supine position may increase blood flow and improve oxygenation 2 – 4 , 7 – 9 , but with potential risks such as increased intracranial pressure, cardiopulmonary dysfunction, and aspiration pneumonia 10 – 13 . The neutral results of the Head Positioning in Acute Stroke Trial (HeadPoST) may have been due to the broad inclusion of stroke patients, particularly of patients with milder deficits, which was a key criticism of the trial.…”

Trendelenburg position for acute anterior circulation ischaemic stroke with large artery atherosclerosis aetiology (HOPES 3): rationale and design

“…The effect of head position (lying flat vs sitting up) as a non-pharmacological therapy for stroke has been widely investigated, [1][2][3][4] but the results remain inconclusive, which has led to ambiguous recommendations by current guidelines. [5][6][7] Compared with the sitting-up position, the supine or lying-flat position can increase blood flow and improve oxygenation, 1-3 8-10 but it may increase the risk of intracranial pressure, cardiopulmonary dysfunction and aspiration pneumonia.…”