Topical Review

Section Editors: Kyra J. Becker, MD, and Emanuela Keller, MD

Head Positioning in Acute Stroke

Down but Not Out
Craig S. Anderson, MD, PhD; Verónica V. Olavarría, MD, MSc

P atients with acute ischemic stroke (AIS) depend on cere-

bral blood flow (CBF) to maintain perfusion of the at-risk
penumbral tissue,1,2 which is critically dependent on arterial
blood pressure when cerebral autoregulation is affected.3
Thus, the simple process of positioning an AIS patient lying
flat or head down is appealing in that it allows gravitational
force to enhance blood flow in the collateral and leptomenin-
geal circulation.4,5 However, as most of the evidence pertain-
ing to the effects of head positioning have been derived from
studies with small, nonrandomized, and nonblinded assess-
ment of physiological parameters in subjects,4,5 these data are
prone to considerable bias and, not unexpectedly, has resulted
in guidelines differing, or making no specific recommenda-
tion, as to the optimal head position for patients with acute
stroke. Japanese guidelines, for example, recommend that
patients with suspected acute stroke be placed head down to
improve CBF in the prehospital phase,6 while other guide-
lines recommend the head-up position in the hospital to re-
duce intracranial pressure and risk of aspiration pneumonia.7–9
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blood pressure, oxygenation, and functional outcome. In particular,
studies were included that reported effects of head positioning by
measurement of mean CBF velocities using transcranial Doppler in
AIS patients that allowed quantification in the meta-analysis.
Lying-Flat Head Position on CBF in AIS
A systematic review and meta-analysis of the association of head
positioning on CBF12 found a total of only 57 AIS patients among
4 observational studies published until October 2013 (Figure in the
online-only Data Supplement).5,13–15 The conclusions were that chang-
ing the position of an AIS patient’s head from 30º to 0º, and from 30º
to 15º, significantly increased mean CBF velocities (cm/s) on tran-
scranial Doppler in the ranges (95% CI of 5.3–11.3 [P<0.001] and
2.9–6.2 [P<0.001], respectively, in the affected cerebral hemisphere
(Figure 1).12 These data were subsequently confirmed in the only ran-
domized evaluation of CBF in hemispheric AIS, conducted across 3
centers in a cluster crossover design with monthly randomized inter-
ventional periods, as a prelude to the main HeadPoST study.16 This
HeadPoST pilot study included 94 patients with hemispheric AIS of
mild-moderate severity (National Institutes of Health Stroke Scale
[NIHSS] score, median [interquartile range], 6 [3–12]), including
one-fifth with severe occlusion of the affected vessel in the anterior

Consequently, there is considerable variability in clinical pro-
tocols and views among physicians about head positioning in
acute stroke.10 In this review, we examine the current evidence
on head positioning, and discuss the first large-scale ran-
domized evaluation, the HeadPoST (Head Position in Acute
Stroke Trial),11 which attempted to resolve such uncertainty
by quantifying the balance of potential benefits and harms of
lying-flat versus sitting-up, head positioning on clinical out-
comes in patients with acute stroke.
Methodology
We undertook a review of published systematic reviews, meta-anal-
ysis, and randomized clinical trials on the effects of head positioning
in acute stroke. We used the following search terms: cerebrovascular
disease, stroke, cerebral infarction, intracerebral hemorrhage (ICH),
head position, head posture, body position, systematic reviews,
randomized clinical trials, and modified Rankin scale (mRS). We
searched PUBMED and OVID-MEDLINE for articles published
from January 2013 to July 2018. We also included articles if they
were prospective cohort-based in their assessment of the effects of
head positioning in acute stroke that reported measurements of CBF,
circulation, with the most positioned within several hours after the
onset of symptoms (mean time to head positioning ≤5.0 hours) and a
median time (hours) in the allocated head position of 45 (IQR, 40–45)
and 45 (40–44) in the lying-flat and upright head positions, respec-
tively. The study showed a significantly greater increase in CBF (de-
fined as ≥8 cm/s) in the affected hemisphere on transcranial Doppler
at 1 and 24 hours after head positioning in the patients lying-flat as
compared with those sitting-up (adjusted odds ratio, 3.81; 95% CI,
1.07–13.54 and adjusted odds ratio, 3.04; 95% CI, 1.08–8.53, respec-
tively). Although the study was not powered to assess the effects on
clinical outcomes, there were no differences in early neurological im-
pairment (an ordinal analysis of NIHSS scores at 7 days) or blinded
assessment of functional recovery on the mRS at 90 days (adjusted
odds ratio, 1.38; 95% CI, 0.64–3.0; P=0.42). These combined tran-
scranial Doppler data indicate a clear increase in CBF provided by the
lying-flat position after AIS (Figure 1). However, 2 critical clinical
questions arise from this important preliminary work: (1) does this
physiological effect translate into improved clinical outcomes and (2)
can head positioning be readily implemented into routine practice.
The HeadPoST study11 was, therefore, initiated to provide reliable
answers to each of these questions through an effectiveness assessment
of the 2 different head positions on clinical outcomes in a broad range of
patients with acute stroke. As clinicians expect, and clinical guidelines

Received August 8, 2018; final revision received October 18, 2018; accepted November 12, 2018.
From the The George Institute for Global Health Australia, University of New South Wales, Sydney, Australia (C.S.A.); Department of Neurology,
Royal Prince Alfred Hospital, Sydney, NSW, Australia (C.S.A.); The George Institute China at Peking University Health Science Center, Beijing, PR China
(C.S.A.); Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría y Departamento de Paciente Crítico, Clínica
Alemana de Santiago (V.V.O.); and Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile (V.V.O.).
The online-only Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.118.020087.
Correspondence to Craig S. Anderson, MD, PhD, The George Institute for Global Health, PO Box M201, Missenden Rd, Camperdown, NSW 2050,
Australia. Email canderson@georgeinstitute.org.au
(Stroke. 2019;50:00-00. DOI: 10.1161/STROKEAHA.118.020087.)
© 2018 American Heart Association, Inc.
Stroke is available at https://www.ahajournals.org/journal/str DOI: 10.1161/STROKEAHA.118.020087

1
 2  Stroke  January 2019

Figure 1.  Difference mean flow velocity of middle cerebral artery on affected side between lying-flat vs upright position: meta-analysis of observational and
randomized controlled studies using transcranial Doppler (TCD) in acute ischemic stroke. Effects of head position change on mean flow velocity (MFV) in the
middle cerebral artery on the affected cerebral hemisphere: meta-analysis of 4 observational studies and 1 cluster crossover clinical trial using TCD in acute
ischemic stroke. For each study and each comparison, the mean difference in MFV was estimated, with overall estimates of effect and 95% CIs calculated
using a fixed-effects model and inverse variance weighting. Boxes and horizontal lines represent mean difference and 95% CI for each study; size of boxes
is proportional to the inverse of variance of the study results. Diamonds show 95% CI for pooled estimates of effect and are centered on pooled mean differ-
ence. HeadPoST indicates Head Position in Acute Stroke Trial; and HOBOE, Head-of-Bed Optimization of Elevation study.

require, practice recommendations to be based on high-quality evi-
dence, the study was designed to assess the treatment effects on the
conventional, patient-centered, 90-day disability outcome (mRS). A
simple, pragmatic, active comparative, cluster randomized crossover
design was used to ensure the study could be undertaken efficiently
(time, quality, and funding) to evaluate lying-flat versus sitting-up (≥30
degrees) head positioning as a model of care to allow recruitment of the
large number of patients required to ensure statistical power for detect-
ing any likely, plausibly modest, treatment effect, the size of which was
akin to that of a neuroprotective rather than a reperfusion agent. The
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in mRS scores for the head down position, unadjusted OR, 1.01;
95% CI, 0.92–1.10; P=0.84; Figure 2). There was similarly no effect
detected in sensitivity analyses, across any of the secondary outcome
(except on the visual-analog scale for health-related quality of life
favoring lying-flat, which was probably a spurious finding), in prede-
fined subgroups (Figure 3), or in serious adverse events.
A different approach proposed by the University of California,
Los Angeles brain attack team is for the head-up position to be used
as a collateral stressor for identifying AIS patients vulnerable to crit-
ical hemodynamic failure and who may benefit from rapid recana-

cluster design, with use of guardian consent to apply the intervention
and individual patient consent for data collection and follow-up, was
considered preferable over the standard, individual patient randomized,
parallel group design because (1) the randomized head position could
be applied quickly and with low resource utilization across groups of
patients as part of routine care, thus avoiding the risk of contamination
that can occur when different management interventions are applied to
individual patients; (2) there is sufficient uncertainty over which partic-
ular characteristics define a subgroup(s) of patients who could derive
the greatest potential benefit (or harm) from a particular head position;
(3) where use of advanced brain imaging for such diagnostic screening
assessment in all patients would introduce a barrier to recruitment, in-
crease costs, and is inconsistent with routine clinical practice; and (4)
the crossover component provided efficiency gains in terms of sample
size estimates and feasibility.
The study enrolled 11 095 stroke patients (mean age 68 years),
including 9485 with AIS, over just under 2 years, which may in part
reflect the interest of investigators and in part the efficiency of the
study design and organization. Although the overall clinical severity
of patients was mild (NIHSS score, median 4 [2–8]), this pattern is
consistent with the profile of stroke patients in routine practice, which
together with the balanced characteristics of the randomized groups,
provides reassurance that there was no substantial selection bias
overall, particularly between the treatment phases, and of generaliza-
bility. However, the median times from the onset of symptoms to head
positioning, and of presentation to the hospital and head positioning,
were 14 and 7 hours, respectively, which while similar in both groups,
were arguably too long from the viewpoint of intervening to affect
the ischemic penumbra which in most cases diminishes over several
hours. Independent monitoring ensured fidelity of the protocol and
each intervention, and no apparent bias was introduced by carry-over
effects into the different treatment phases, differential drop-out or
lost-to-follow-up between the groups, or in the assessment of main
outcomes which were predominantly done centrally.
The HeadPoST study found a precise, nonsignificant between-
group difference, in the functional recovery of patients (difference
lization therapy.17 However, not all the 5 patients in the series with
symptoms in the head-up maneuver responded to lying-flat, and there
is uncertainty over how this maneuver would help triage patients over
brain imaging with angiography and perfusion to assess the site of
occlusion and extent of collateral circulation.
Effect of Head Positioning on Other
Physiological Parameters
As obese patients may have altered cardiorespiratory function, a
small randomized trial was undertaken to assess the effects of differ-
ent head positions on oxygenation during anesthesia.18 In 42 morbidly
obese patients about to undergo laparoscopic adjustable band surgery,
those allocated to a sitting-up (25 degrees) position versus the supine
position before anesthesia had 23% greater preinduction oxygen ten-
sions and took longer to achieve an oxygen desaturation (92%) during
induction, suggesting better oxygenation in the sitting-up position.18
However, a systematic review of 10 observational studies of body
positioning and physiological homeostasis19 found conflicting results
for the effects on oxygen saturation: some showing higher mean levels
in the semirecumbent position compared with the supine position,20,21
while others have reported no change.22,23 In regard to any effects on
blood pressure, some small studies have either shown a small increase
in the supine position, or a fall early after the sitting-up position, in
patients with acute stroke of mild to moderate severity.13,24 There is
similarly ambiguous data on CBF using single photon emission to-
mography, such that a review concluded the evidence is insufficient
to make any firm recommendations.19 Most recently, nonrandomized
comparative study suggests that patients with large vessel occlusive
AIS had improved early neurological function (≥4 increase in NIHSS
scores over 48 hours) after being placed in the Trendelenburg position
(feet higher than the head by 0–15 degrees) compared with recovery
in an historical control group who had received standard positioning
(0–30 degrees).25
In the HeadPoST study, there were no significant between-
group differences in systolic and diastolic blood pressure at 4-hour
 Anderson et al   Head Positioning in Stroke   3

Figure 2.  There was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale (mRS) between patients in the
lying-flat group and those in the sitting-up group (odds ratio, 1.01; 95% CI, 0.92–1.10; P=0.84) by using a hierarchical linear mixed model adjusted for the
cluster crossover design effects in the HeadPoST (Head Position in Acute Stroke Trial).11 Scores on the mRS range from 0 to 6, with 0 indicating no symp-
toms, 1 symptom without clinical significant disability, 2 slight disability, 3 moderate disability, 4 moderately severe disability, 5 severe disability, and 6 death.

intervals over 24 hours nor when analyzed separately for AIS and Effect of Head Position on ICH
ICH patients.11 Similarly, the oxygen saturation levels of participants Evidence of the effect of head position specifically in ICH patients is
remained stable between the randomized groups. scarce. A systematic review of observational studies which assessed
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Figure 3.  Effects of lying-flat compared with

sitting-up on the primary efficacy outcome (or-
dinal shift analysis the full range of modified
Rankin scale scores 0–6), according to prede-
fined subgroups in the HeadPoST (Head Po-
sition in Acute Stroke Trial).11 NIHSS indicates
National Institutes of Health Stroke Scale.
 4  Stroke  January 2019
the association of the backrest position on intracranial pressure and
cerebral perfusion pressure in patients with brain injury showed
that intracranial pressure reduced when the head was elevated to 30
degrees, but the effects on cerebral perfusion pressure were varied.
Those findings have been used as an argument for using the sitting-up
position to decrease intracranial pressure in acute ICH.26 However, in
the HeadPoST study, which included 931 ICH patients, 420 and 511
allocated to lying-flat and sitting-up, respectively, there was no sig-
nificant between-group difference in the primary outcome (ordinal
analysis of the mRS, unadjusted OR, 0.99; 95% CI, 0.71–1.39) nor
across any of the secondary outcomes.
Potential Harms of Different Head Positions
A common concern is that respiratory function could be compro-
mised when patients are lying-flat, either because of restriction of
the diaphragm and sleep apnea in the obese patient, and of aspi-
ration pneumonia. The HeadPoST study found no differences in
the rates of pneumonia between the randomized groups. Yet, de-
spite the protocol stipulating recruitment of consecutive patients,
it is likely there was selection bias related to the attending clini-
cian considering whether either position may be harmful, as well
as other factors. Moreover, patients were likely to have received a
more vigorous assessment of dysphagia and use of assisted feed-
ing than undertaken routinely outside of a trial setting. All these
factors are likely to explain the relatively low rate of pneumonia
(3%) in the study. An important conclusion from HeadPoST is that
lying-flat does not increase the risk of pneumonia in the context of
background standard of stroke unit care with dysphagia screening
and management strategies.
Conclusions
A limitation of this review is our interpretation of the current
evidence which is based on a limited number of small obser-
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vational physiological studies, with variable designs, inclu-
sion criteria and measures; and only one randomized clinical
end point trial. As in other large-scale pragmatic trials, a com-
mon argument over the neutral results of the HeadPoST study
is that it included the wrong patients.27 A key advantage of
such a study, however, is the ability to undertake a compre-
hensive analysis of subgroups where there are separately large
numbers of patients. Importantly, meaningful dose-response
relationships were explored for the key variables of (1) time
from symptom onset, (2) neurological severity (NIHSS scale),
and (3) across clinician-diagnosed pathological stroke sub-
types, without any evidence of statistical heterogeneity being
detected. As emphasized elsewhere,28 it is most unusual for
a significant effect to be detected in a subgroup of a well-
powered trial without any trends being detected and when
the overall result is so clearly neutral. While certain types of
patients may still benefit from certain head positioning—for
example, the lying-flat head position in those with large vessel
occlusive AIS, or the sitting-up position in those with large
ICH—the current evidence would suggest this is unlikely.
While the evidence is reasonably strong for certain physi-
ological functions to be altered for head positioning, particu-
larly of CBF in the large proximal anterior circulation cerebral
vessels in the lying-flat position, there is no evidence that this
translates into a clinical benefit. Moreover, the HeadPoST
study indicates that the routine application of a standard head
position to all stroke patients is unnecessary. It remains to be
clearly demonstrated that the various hypotheses proposed
over certain changes in the cerebral circulation26 can have a
clinical benefit and are applicable to patient care.
Acknowledgments
We thank Pablo Lavados and Hisatomi Arima for advice on this ar-
ticle. Dr Anderson holds a Senior Principal Research Fellowship
from the National Health and Medical Research Council of Australia.
Disclosures
Drs Anderson and Olavarría were members of the Steering
Committee of the HeadPoST (Head Position in Acute Stroke Trial)
study, for which they received research grants from the National
Health and Medical Research Council (NHMRC) of Australia and
Clínica Alemana de Santiago, Chile. Dr Anderson acknowledges that
he has received advisory committee fees from Amgen, Boehringer
Ingelheim, and honoraria from Takeda China. Dr Olavarría has re-
ceived a research grant from Clínica Alemana de Santiago.
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Key Words: blood pressure ◼ cerebral hemorrhage ◼ intracranial pressure
◼ pneumonia ◼ stroke