Cluster-randomized, crossover trial of head positioning in acute stroke—have we lost our position on this?

One of the earliest documentation of postural change leading to reversible clinical worsening of neurological symptoms was documented in 1976 in four patients with occlusive cerebral arterial disease (1). Elevation of the head of the bed resulted in deterioration in function, from which patients recovered with resumption of the supine position. Since then, the effect of head positioning on cerebral perfusion pressure, cerebral blood flow, electroencephalography, mean flow velocity in MCAs, and intracranial pressure have been described in small studies of acutely brain injured animals with induced stroke and humans with spontaneous stroke (2-5). Improvement in cerebral blood flow and neurological function has been demonstrated by the simple and zero-cost intervention of placing the head of bed position flat in some series (3,6). In other studies, deterioration after elevation of the head of the bed has been used to guide the decision whether to offer endovascular treatment for a large vessel occlusion with low NIHSS score after assuming supine positioning (7). If there was no potential adverse effect of the supine position in patients with acute stroke, it would be hard to argue against this as a universal practice.