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No benefit of flat head positioning in early moderate–severe acute ischaemic stroke: a HeadPoST study subgroup analysis
  1. Alejandro M Brunser1,2,
  2. Menglu Ouyang3,4,
  3. Hisatomi Arima5,
  4. Pablo M Lavados2,
  5. Thompson Robinson6,
  6. Paula Muñoz-Venturelli2,3,
  7. Verónica V Olavarría2,
  8. Laurent Billot3,
  9. Marre L Hackett3,7,
  10. Lili Song3,4,
  11. Sandy Middleton8,
  12. Octavio Pontes-Neto9,
  13. Tsong-Hai Lee10,
  14. Caroline Watkins7,
  15. Craig S Anderson3,4
  1. 1 Department of General Emergency, Clínica Alemana de Santiago, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
  2. 2 Department of Neurology and Psychiatry, Clínica Alemana de Santiago, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
  3. 3 The George Institute for Global Health, University of New South Wales, Sidney, New South Wales, Australia
  4. 4 The George Institute in China, Peking University Health Science Center, Beijing, China
  5. 5 Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan
  6. 6 Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
  7. 7 Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK
  8. 8 Nursing Research Institute, St Vincent's Health Network Sydney Australia, Australian Catholic University, Sydney, New South Wales, Australia
  9. 9 Stroke Service-Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of Sao Paulo, Sao Paulo, Brazil
  10. 10 Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
  1. Correspondence to Dr Alejandro M Brunser; abrunser2017{at}


Background Although the Head Positioning in acute Stroke Trial (HeadPoST) showed no effect of the flat head position (FP; vs sitting up head position (SUP)) on functional outcome, we hypothesised that it could still offer benefits if commenced early in those with acute ischaemic stroke (AIS) of at least moderate severity.

Methods Subgroup analysis of HeadPoST in participants with National Institutes of Health Stroke Scale (NIHSS) scores ≥7, ≥10 and ≥14, randomised to FP or SUP <4.5 hours of AIS onset on functional outcomes defined by a shift in scores on the modified Rankin scale (mRS) and death/disability (mRS scores 3–6), and any cardiovascular serious adverse event. Logistic regression analyses were undertaken adjusted for study design and baseline risk factors.

Results There was no significant differential treatment effect in patient subgroups defined by increasing baseline NIHSS scores: adjusted OR and 95% CI for ordinal shift and binary (3–6) mRS scores: for NIHSS ≥7 (n=867) 0.92 (0.67 to 1.25) and 0.74 (0.52 to 1.04); NIHSS ≥ 10 (n=606) 0.80 (0.58 to 1.10) and 0.77 (0.49 to 1.19); NIHSS ≥14 (n=378) 0.82 (0.54 to 1.24) and 1.22 (0.69 to 2.14).

Conclusions Early FP had no significant effect in patients with moderate–severe AIS.

Trial registration number NCT02162017.

  • stroke

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  • Contributors AMB and MO: design substudy. LB: did the statistical analysis. All authors participated in their local centres for patients recruitment, and review this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AB reports research grants from Clínica Alemana de Santiago. PML reports research grants from The George Institute, Clínica Alemana de Santiago, and the Chilean Government, personal fees from Bristol Meyer Squibb, AstraZeneca and Bayer, and an unrestricted research grant from Lundbeck. TR is a National Institutes for Health Research Senior Investigator. VVO reports research grants from Clínica Alemana de Santiago, Boehringer-Ingelheim and Conicyt. PM-V reports research grants from Clínica Alemana de Santiago. MLH holds a National Health and Medical Research Council (NHMRC) of Australia Career Development Fellowship. SM is a member of the NHMRC Research Committee in 2015–2018. OP-N reports research grants for the Brazilian Stroke Research Network from the Brazilian government. CSA holds an NHMRC Senior Principal Research Fellowship, and reports honoraria and travel reimbursement from Takeda, Boehringer Ingelheim and Amgen.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.