Head Positioning and Other Strategies in Stroke Care

Abstract

Background Stroke is the second major cause of death and a leading cause of disability, particularly so in low and middle-income countries. There are numerous gaps in stroke care and inconsistencies in clinical practice around the world. Aim To identify and test simple, widely applicable strategies with the potential to improve outcome after acute. Methods First, survey instruments were created to capture information on current practice in stroke care in different health care settings of countries. Next, a stepwise approach was undertaken to provide evidence about the effectiveness and safety of different head positioning of patients with acute stroke patients, beginning with a pilot phase to a cluster randomised clinical trial - HeadPoST pilot – leading to the protocol for the main phase of the HeadPoST trial, a large international, multicentre, cluster randomised clinical trial. Secondary post-hoc analyses were undertaken of the large database of INTERACT2, an international multicenter clinical trial of intensive BP lowering treatment in stroke due to acute intracerebral haemorrhage (ICH). The statistical methods used for this work included propensity score, logistic regression, and multivariable analyses. Results Major differences were detected in organisation of stroke care across various hospitals in middle-income and high-income countries. In particular, there was variation in clinical practice related to uncertainty over, with a lack in protocols, of an ideal head position for patients who experience acute stroke. The pilot trial showed that the lying flat head position was associated with an increase in cerebral blood flow velocity in patients with acute ischaemic stroke as compared to sitting up position, providing a proof of concept for the potential benefit of this approach on clinical outcomes of participants in the ongoing main phase of the HeadPoST in over 100 hospitals, worldwide. In patients with acute ICH, use of heparin within the first 7 days was significantly associated with an increased risk of poor outcome. The effect was driven largely by those who received heparin surviving with greater residual disability. Further analysis of the INTERACT2 dataset showed that a decision to withdrawal active treatment was most often made in patients with poor prognosis, with resulting higher mortality and increased disability among survivors, despite having received more intensive early in-hospital management. Patients with severe ICH often require admission to an intensive care unit (ICU) and were related to poor outcome. A set of clinical variables was identified that predict ICU admission, and prolonged length of stay and outcomes from ICU, again using the INTERACT2 database. Finally, analysis of the INTERACT2 database indicates that use of mannitol in ICH patients appears safe but did not clearly improve outcomes, while admission hyperglycaemia was associated with poor outcome and suggested a direct deleterious hyperglycaemia after the onset of this condition. Discussion Several aspects of this thesis support the hypothesis that there are benefits of lying flat in the acute phase of ischaemic stroke. Given scarce randomised evidence, the findings herein provide a solid foundation for sensible clinical decision-making and development of guideline recommendations over the management of patients with acute stroke.