Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke

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dc.contributor.authorAnderson, Craig
dc.contributor.authorArima, Hisatomi
dc.contributor.authorLavados, Pablo
dc.contributor.authorBillot, Laurent
dc.contributor.authorHackett, Maree
dc.contributor.authorOlavarría, Verónica
dc.contributor.authorMuñoz Venturelli, Paula
dc.contributor.authorBrunser, Alejandro
dc.contributor.authorPeng, Bin
dc.contributor.authorCui, Liying
dc.contributor.authorSong, Lily
dc.contributor.authorRogers, Kris
dc.contributor.authorMiddleton, Sandy
dc.contributor.authorLim, Joyce Y.
dc.contributor.authorForshaw, Denise
dc.contributor.authorLightbody, Elizabeth
dc.contributor.authorWoodward, Mark
dc.contributor.authorPontes-Neto, Octavio
dc.contributor.authorDe Silva, Asita
dc.contributor.authorLin, Ruey-Tay
dc.contributor.authorLee, Tsong-Hai
dc.contributor.authorPandian, Jeyaraj D.
dc.contributor.authorMead, Gillian E.
dc.contributor.authorRobinson, Thompson
dc.contributor.authorWatkins, Caroline
dc.contributor.authorHeadPoST Investigators and Coordinators
dc.date.accessioned2017-10-03T15:15:43Z
dc.date.available2017-10-03T15:15:43Z
dc.date.issued2017
dc.description.abstractBACKGROUND: 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 ClinicalTrials.gov number, NCT02162017.)
dc.description.versionVersión Publicada
dc.format.extent10
dc.identifier.citationAnderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, Muñoz Venturelli P, Brunser A, Peng B, Cui L, Song L, Rogers K, Middleton S, Lim JY, Forshaw D, Lightbody CE, Woodward M, Pontes-Neto O, De Silva HA, Lin RT, Lee TH, Pandian JD, Mead GE, Robinson T, Watkins C; HeadPoST Investigators and Coordinators. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017 Jun 22;376(25):2437-2447. doi: 10.1056/NEJMoa1615715
dc.identifier.urihttp://hdl.handle.net/11447/1687
dc.identifier.urihttp://dx.doi.org/10.1056/NEJMoa1615715
dc.language.isoen_US
dc.publisherMassachusetts Medical Society
dc.sourceThe New England Journal of Medicine
dc.subjecthead position
dc.subjectcluster-randomized
dc.subjectAcute stroke
dc.titleCluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke
dc.typeArtículo

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