Rights statement: Copyright © 2017 Massachusetts Medical Society. All rights reserved.
Final published version, 327 KB, PDF document
Available under license: None
Final published version
Research output: Contribution to Journal/Magazine › Journal article › peer-review
Research output: Contribution to Journal/Magazine › Journal article › peer-review
}
TY - JOUR
T1 - Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke
AU - Anderson, Craig S.
AU - Arima, Hisatomi
AU - Lavados, Pablo
AU - Billot, Laurent
AU - Hackett, Maree L.
AU - Olavarría, Verónica V.
AU - Venturelli, Paula Muñoz
AU - Brunser, Alejandro
AU - Peng, Bin
AU - Cui, Liying
AU - Song, Lily
AU - Rogers, KrIs
AU - Middleton, Sandy
AU - Lim, Joyce Y.
AU - Forshaw, Denise
AU - Lightbody, Elizabeth
AU - Woodward, Mark
AU - Pontes-Neto, Octavio
AU - De Silva, Asita
AU - Lin, Ruey-Tay
AU - Lee, Tsong-Hai
AU - Pandian, Jeyaraj D.
AU - Mead, Gillian E.
AU - Robinson, Thompson
AU - Watkins, Caroline
AU - Emsley, Hedley
AU - HeadPoST Investigators and Coordinators
PY - 2017/6/22
Y1 - 2017/6/22
N2 - BACKGROUNDThe 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. METHODSIn 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).RESULTSThe 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.CONCLUSIONSDisability 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 ClinicalTrials.gov number, NCT02162017.)
AB - BACKGROUNDThe 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. METHODSIn 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).RESULTSThe 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.CONCLUSIONSDisability 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 ClinicalTrials.gov number, NCT02162017.)
U2 - 10.1056/NEJMoa1615715
DO - 10.1056/NEJMoa1615715
M3 - Journal article
VL - 376
SP - 2437
EP - 2447
JO - New England Journal of Medicine
JF - New England Journal of Medicine
SN - 0028-4793
ER -