Heads down

CME
Flat positioning improves blood flow velocity in
acute ischemic stroke
Anne W. Wojner-Alexander, PhD; Zsolt Garami, MD; Oleg Y. Chernyshev, MD, PhD;
and Andrei V. Alexandrov, MD

Abstract—Background: Acute stroke patients are routinely positioned with the head of the bed (HOB) elevated at 30°
despite lack of evidence for increased intracranial pressure. Objectives: To determine the effect of HOB positions in real
time on residual blood flow velocity in acutely occluded arteries causing stroke and whether resistance to residual flow
increased with lower HOB positions. Methods: In a repeated-measures quasi-experiment, the effect of 30, 15, and 0° HOB
on middle cerebral artery (MCA) mean flow velocity (MFV) in patients with acute (⬍24 hours) ischemic stroke was
measured with transcranial Doppler using MFV and pulsatility index (PI) of the residual flow signals at the site of
persisting acute occlusion. Results: Twenty patients were evaluated (mean age 60 ⫾ 15 years; median NIH Stroke Scale
[NIHSS] score 14 points). MCA MFV increased in all patients with lowering head position (maximum absolute MFV value
increase 27 cm/s, range 5 to 96% from baseline values at 30°). On average, MCA MFV increased 20% (12% from 30 to 15°
and 8% from 15 to 0°; p ⱕ 0.025). Mean arterial pressure and heart rate were unchanged throughout the intervention. PI
remained unchanged (mean values 0.89 at 30° elevation, 0.91 at 15° elevation, and 0.83 at 0° elevation) at each HOB
position, indicating no increase in resistance to blood flow. Immediate neurologic improvement (average 3 NIHSS motor
points) occurred in three patients (15%) after lowering head position. Conclusion: Acute ischemic stroke patients may
benefit from lower head-of-the-bed positions to promote residual blood flow to ischemic brain tissue.
NEUROLOGY 2005;64:1354 –1357

Ischemic stroke is a potentially reversible process
that is dependent on restoration of arterial blood
flow within a window of cellular viability that varies
according to the severity and duration of the flow
deficit. Measures that promote blood flow during the
acute phase of ischemic stroke may directly impact
the subsequent development of brain infarction and
associated clinical deficit. One such measure may be
flat head-of-the-bed (HOB) positioning to promote a
gravity-induced increase in arterial flow to ischemic
brain tissue; however, patients with stroke and other
neurologic diagnoses are routinely positioned using
30° HOB elevation by paramedics and emergency
room personnel.
Several studies aimed to identify optimal HOB
position for patients with neurologic disorders, often
including heterogeneous samples of patients with
differing diagnoses and potential or actual increases
in intracranial pressure (ICP).1-11 Most HOB posi-
tioning studies included patients with traumatic
brain injury. The studies focused on cerebral perfu-
sion pressure (CPP) variables rather than real-time
arterial flow variables. To date, findings from these
studies have been inconclusive, with some favoring
HOB elevation,1,3,7,9,10 flat positioning,4,11 and posi-
tioning guided by individual patient factors.2,5,6,8
There is only one HOB study consisting entirely of
patients with large subacute ischemic strokes and
normal ICP.12 Whereas ICP and CPP were the pri-
mary variables of interest, these researchers also ob-
tained middle cerebral artery (MCA) mean flow
velocity (MFV) data using transcranial Doppler
(TCD) in 18 anesthetized patients. This study sug-
gested that although ICP was higher in a flat posi-
tion, CPP and MCA MFV were highest when
patients were placed in the 0° HOB position.
We sought to determine if MCA flow velocity could
be augmented by simple HOB positioning during the
acute phase of stroke while avoiding arterial flow
compromise secondary to increased resistance to
flow. We have previously shown the ability to mea-
sure residual flow signals at the point of acute intra-
cranial arterial occlusions using TCD.13 TCD may be
used to grade the severity of arterial occlusion and to
indirectly estimate flow changes if insonation angle
is maintained constant over short observation peri-
ods.14 In ischemic stroke, increased ICP with reduc-
tion of CPP has been reported to peak at or beyond
48 hours post infarction.15-17 Therefore, we did not
anticipate significant aggravation of ICP with lower
HOB positioning during the first 24 hours following
symptom onset.
Methods. A quasi-experimental repeated-measures design was
used to study the effect of 30, 15, and 0° HOB elevation on resid-
ual arterial flow signals in patients with acute ischemic stroke.
Two hypotheses guided this study: 1) MCA MFV would signifi-

From the University of Texas Health Science Center at Houston.

Received September 8, 2004. Accepted in final form January 5, 2005.
Address correspondence and reprint requests to Dr. A.W. Wojner-Alexander, Stroke Team, Department of Neurology, University of Texas Health Science
Center at Houston, 6431 Fannin, MSB 7.044, Houston, TX 77030; e-mail: Anne.W.Wojner@uth.tmc.edu

1354 Copyright © 2005 by AAN Enterprises, Inc.

cantly increase at the point of arterial occlusion when patients
with acute ischemic stroke were placed at lower HOB positions
than the 30° height; and 2) resistance to flow measured by the
pulsatility index (PI) of Gosling and King would remain within
normal low-resistance limits throughout the procedure.
Permission was obtained from the Committee for the Protec-
tion of Human Subjects at a university-affiliated hospital. Esti-
mates of effect size for the intervention had not been previously
published, so pilot data (n ⫽ 11) were analyzed to assist with
determination of sample size, revealing an effect size for the inter-
vention at three levels of 0.40, a minimum r of 0.89, and an
observed power of 0.85 (Greenhouse–Geisser adjusted, f ⫽ 6.34,
p ⫽ 0.22); based on these data, sample size was set at 20 subjects.
Patients gave written informed consent for enrollment in the
study and included those over age 18 presenting with anterior
circulation stroke and persisting arterial occlusion with residual
flow signals obtainable by TCD within 24 hours of symptom onset.
In brief, TCD was performed over the temporal bone window on
the affected brain side. MCA waveforms were identified at depth
range of 40 to 65 mm, and the worst abnormal Thrombolysis in
Brain Ischemia (TIBI) waveform was selected for monitoring.13
The accuracy parameters of TCD to detect acute M1 MCA occlu-
sions compared to angiography exceed 90% at our laboratory. Pa-
tients with hemorrhagic stroke or posterior circulation ischemic
stroke were excluded from the study, as well as those lacking a
transtemporal window for insonation and those achieving com-
plete recanalization prior to completion of the study protocol.
TCD probes were mounted to the transtemporal window by
headframe to ensure a constant angle of insonation throughout
the procedure. MFV served as the dependent variable in this
study and was used to detect changes in arterial blood flow in
association with HOB positioning. PI measurements calculated in
relation to MFV values at 30, 15, and 0° HOB elevation were used
to reflect the degree of resistance to flow incurred with position
change, such as that which might occur with an increase in ICP.
The study protocol was initiated with the patient at 30° HOB
elevation; MFV, PI, heart rate, and systolic, diastolic, and mean
arterial pressure (MAP) were obtained. Then the patient was re-
positioned to the 15° and subsequently 0° HOB positions. An
equilibration period of 15 minutes was instituted between mea-
surements at each HOB height change to ensure stability of both
heart rate and arterial pressure to avoid a confounding influence
on MFV. Data were entered and analyzed using SPSS (Cary, NC).
Statistical analysis included Student t test and repeated-
measures analysis of variance (ANOVA); Greenhouse–Geisser ad-
justment of the f statistic was used to ensure conservative
interpretation of the results. Bonferroni correction of the ␣ to
0.016 was performed to control for a galloping ␣ effect.
Results. Twenty awake patients with acute ischemic
stroke who underwent neurologic examination, CT, and
TCD were enrolled in the study. All patients had persist-
ing MCA occlusions on TCD with detectable abnormal re-
sidual flow signals (TIBI grades 1 to 3, n ⫽ 11 left MCA,
n ⫽ 9 right MCA). Mean age was 60 ⫾ 15 years (median 65
years, range 27 to 87 years), with 14 men and 6 women.
Median NIH Stroke Scale (NIHSS) score at the time of
initial TCD assessment was 14 points (range 3 to 24
points).
We observed MCA MFV improvement in all patients
with lowering head position (maximum absolute MFV
value increase 27 cm/s, range 5 to 96% from baseline val-
ues at 30°). An average total increase in the MCA MFV
was 20% when HOB was lowered from 30 to 0° (table 1).
MCA MFV values differed between the three HOB levels,
and the calculated effect size for the intervention at three
levels was 0.47 with a minimum r of 0.90 and an observed
power of 0.99 (table 2). A difference in MFV was detected
when HOB elevation was decreased from 30 to 15° (Stu-
dent t test, p ⬍ 0.001) and from 30 to 0° (p ⬍ 0.001);
decreasing the HOB from 15 to 0° produced a further in-
crease in the MCA MFV (p ⫽ 0.025; however, it was not
Table 1 Yield of mean flow velocity (MFV) by head-of-bed (HOB)
reduction
% increase in
HOB reduction MCA/MFV MFV
HOB 30°, starting point 40.1 (17.6) Baseline flow
HOB lowered to 15° 44.9 (18.6) 12% flow increase
HOB lowered to 0° 48.3 (19.1) 8% flow increase
Total yield 20% flow increase
Values in parentheses are SD.
MCA ⫽ middle cerebral artery.
significant with Bonferroni correction). Most of the change
in MFV (12%) was produced by decreasing the HOB from
30 to 15° (see table 1). The figure illustrates the increase in
MCA MFV achieved through lowering HOB positioning.
No significant difference was measured in MAP or heart
rate for any HOB position change during the study proce-
dure. In 11 subjects (55%), MAP decreased slightly from its
original 30° value, but MFV increased despite this change,
demonstrating independence from systemic perfusion pres-
sure as the sole mechanism that could be driving arterial
flow velocity.
The observed increase in the MCA MFV did not lead to
or occurred at the expense of increased resistance to arte-
rial flow. PI was assessed for each associated MFV mea-
sure at the three HOB positions and remained within
normal limits with no significant differences between mea-
sures (NS, repeated-measures ANOVA). On average, PI
was 0.89 (SD ⫽ 0.28) at 30° HOB elevation, 0.91 (SD ⫽
0.29) at 15° HOB elevation, and 0.83 (SD ⫽ 0.28) with the
HOB at 0° elevation.
When patients were placed in a flat head position, neu-
rologic improvement was observed in 3 of 20 patients. No
patient was receiving thrombolytic therapy prior to or at
the time of TCD measurements. Patients demonstrated
improvement in arm or leg strength (average decrease of
the NIHSS score by 3 points, items 5 and 6) (see figure).
Discussion. Our study showed that decreasing
HOB elevation from a height of 30° to the 0° position
resulted on average in a 20% increase in the mean
velocity of the residual arterial blood flow in the
affected artery following acute ischemic stroke. At
the same time, flow pulsatility remained unchanged
within low resistance parameters throughout the
procedure, indicating no increase in resistance to
flow from a potential increase in ICP. Although TCD
MFV measurements cannot be used to calculate ce-
rebral blood flow (CBF) volume, the observed rela-
tive change in MFV can be proportionate to the
change in CBF as the angle of insonation and sys-
temic flow parameters remained constant during
short testing time in our study.14
The findings from this study suggest that 0° head
positioning may improve residual flow in the affected
MCA. First, the combined increase in MFV with nor-
mal PI values may suggest that the vasculature dis-
tal to the occlusion may undergo passive vasodilation
whereby blood flow is driven by local perfusion pres-
April (2 of 2) 2005 NEUROLOGY 64 1355
Table 2 Differences in mean flow velocity by head-of-bed (HOB) elevation
Paired differences
Paired variables Mean SD
HOB 30° and HOB 15° ⫺4.8 3.9
HOB 30° and HOB 0° ⫺8.2 8.2
HOB 15° and HOB 0° ⫺3.4 6.1
* Bonferroni-corrected ␣ ⫽ 0.016, NS.
sure gradients. These gradients can be higher when
the HOB is placed flat owing to gravitational force.
Additionally, the persistence of normal PI values in
combination with higher MFV indicates an increase
in the end-diastolic velocity. Although there is no
direct way of measuring blood flow volume with
TCD, and the velocity measurement is being limited
to the horizontal portion of the MCA, we think that
the residual flow to ischemic brain is potentially aug-
mented because 1) in a short observation time with
constant angle of insonation, the velocity increased;
and 2) pulsatility remained unchanged. The latter
suggests that velocity increase produces more for-
ward flow at no increase in resistance, thereby
reaching the low-resistance vascular bed of the brain
parenchyma. Therefore, lower HOB positions may
create better circulatory conditions for brain perfu-
sion during diastoli. This observation parallels previ-
ous findings that CPP is higher with flat head
position despite relative increase in ICP in subacute
large ischemic stroke.12 Our study points to the exis-
tence of a similar effect in acute MCA strokes of
lesser clinical severity. Another explanation may be
that the velocity increase may result from improved
collateral flow. In patients with proximal internal
carotid artery occlusions, the residual flow in the
MCA relies on collateral channels at the circle of
Willis. With the current study design, we cannot rule
out the fact that the velocity increase may have been
partially attributable to improvement of transcorti-
cal collateral flow between M2 and M3 MCA
segments.
Use of 0° HOB positioning in the patients with
ischemic stroke led to an increase in the MCA MFV
and some degree of spontaneous neurologic improve-
ment in three patients in our study. The National
Institute of Neurologic Disorders and Stroke rt-PA
investigators noticed that flat head positioning may
lead to immediate neurologic improvement in some
patients, and it was casually observed during pivotal
trials of thrombolysis for acute ischemic stroke (J.C.
1356 NEUROLOGY 64 April (2 of 2) 2005
95% CI t df p
⫺6.67 to ⫺2.93 ⫺5.37 19 ⬍0.001
⫺12.0 to ⫺4.28 ⫺4.42 19 ⬍0.001
⫺6.23 to ⫺.472 ⫺2.4 19 0.025*
Grotta, personal communication, 2004). Further-
more, flat head positioning may improve the ampli-
tude of the residual flow signals, and higher TIBI
flow grades double the chance of tissue plasminogen
activator–associated recanalization.18 The potential
of the Trendelenburg position (⫺15°) to further in-
crease flow with large proximal occlusions should be
further evaluated in select patients with acute ische-
mic stroke.
Certainly, not all patients can tolerate 0° position-
ing for any length of time owing to concurrent cardio-
pulmonary pathology that may challenge flat
positioning. Additionally, the risk of pulmonary aspi-
ration must be considered when prescribing 0° posi-
tioning for a significant length of time. A 12% MFV
increase was observed with reduction of the HOB
from the 30 to the 15° position; given these data,
clinicians should consider use of a 15° position when
0° positioning is poorly tolerated or aspiration risk is
of concern.
Application of the findings of this study to the
routine acute management of ischemic stroke pa-
tients could conceivably go beyond the realm of hos-
pital practice, crossing into care that is delivered in
the prehospital phase by emergency medical system
personnel such as paramedics. Patients with acute
ischemic stroke may benefit from being maintained
in a flat 0° position during stabilization and prehos-
pital transport because residual flow in the MCA can
be augmented using this simple maneuver. Whereas
the etiology of patients’ stroke symptoms would re-
main unknown during the prehospital phase, the im-
provement in arterial flow might outweigh the risk
of potential ICP exacerbation in cases of hemor-
rhagic stroke, although this would warrant further
study. Hence, standard textbooks do not provide a
clear guide as to how the head should be positioned
in acute stroke patients, and their management is
often equated with principles of head trauma
management.19
Replication of this study should be considered us-
Figure. Middle cerebral artery (MCA)
waveforms at 30, 15, and 0° head-of-
the-bed (HOB) positions in a patient
with acute ischemic stroke. During test-
ing, the NIH Stroke Scale score de-
creased by 3 points (arm 2 points, leg 1
point reduction) from the 30 to 0° head
position. PI ⫽ pulsatility index.
ing more sophisticated and direct methods that mea-
sure CBF; however, repeated use of these tests may
not be indicated in routine practice. What also re-
mains unknown is the timeframe for which the effect
of 0° positioning continues to benefit ischemic stroke
patients. We did not attempt to revert patients back
to the upright position if neurologic improvement
was noted with the flat head position. Furthermore,
it is unclear whether a difference in stroke outcome
may be derived from this intervention. It is also un-
known if patients with large strokes and massive
brain edema will show similar trends in cerebral
perfusion.20 In fact, in these patients, flat head posi-
tioning may be detrimental in the subacute phase of
stroke when ICP may raise to life-threatening levels.
Last, it is acknowledged that TCD is a user-
dependent technology and may not detect with 100%
accuracy the presence of critical flow reductions or
flow augmentation in ischemic stroke. Additionally,
the absence of a temporal window for TCD examina-
tion occurs in 5 to 15% of patients,21 eliminating the
possibility of measuring MFV. Although much re-
mains to be learned about this phenomenon, 0 to 15°
HOB positioning may serve as one simple tool in the
management of patients with acute stroke.
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April (2 of 2) 2005 NEUROLOGY 64 1357
 Heads down: Flat positioning improves blood flow velocity in acute ischemic stroke
Anne W. Wojner-Alexander, Zsolt Garami, Oleg Y. Chernyshev, et al.
Neurology 2005;64;1354-1357 Published Online before print April 7, 2005
DOI 10.1212/01.WNL.0000158284.41705.A5

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