Trendelenburg Positioning in Large Vessel Ischaemic Stroke: A Pre-Post Observational Study Using Propensity Score Matching

Abstract

Background: Along with pharmacological and mechanical recanalization, improving cerebral perfusion through the recruitment of collateral vessels during the acute phase of ischaemic stroke (IS) is a clinical challenge. Our objective was to assess the effectiveness and safety of Trendelenburg positioning (TP), a procedure intended to increase cerebral blood flow, on the outcome of IS. Methods: Two cohorts of patients with an acute supratentorial IS related to a large artery occlusion were compared. In the first cohort (n = 119), we used standard positioning (0 to +30°); in the second cohort (n = 90), we used TP (0 to –15°). The primary outcome measure was the improvement of National Institutes of Health Stroke Scale (NIHSS) score between admission and day 2. Factors associated with an improvement ≥4 points of NIHSS score were assessed using multiple logistic regression and propensity score (PS) matching analyses. Results: TP was significantly associated with a greater improvement of NIHSS score within 48 h following stroke onset (4.0 ± 5.7 vs. 1.8 ± 5.9, p = 0.011) but also at discharge (p = 0.005). Multiple logistic regression analysis suggested that TP was an independent predictor of early neurological improvement (adjusted OR 1.81, 95% CI 1.00–3.27) in a model controlling recanalization and haemoglobin level. In addition, PS matching analysis confirmed the possible effectiveness of TP (unadjusted OR 1.99, 95% CI 1.04–3.82), especially in male subjects. The effect of TP was more pronounced in patients with admission mean arterial blood pressure ≥100 mm Hg, those exhibiting a good collateral vessel network on admission CT-angiography or experiencing an effective recanalization. Furthermore, TP was not associated with life-threatening complications. Conclusion: TP could be an effective and safe strategy in patients with large IS resulting from the proximal occlusion of a large vessel.

Impact of Head‐Down Position on Cerebral Blood Flow in Healthy Subjects: An Arterial Spin‐Labeling MR Perfusion Study

“…Different therapeutic means exist to maintain or increase BP in stroke patients (interrupting hypotensive medication, hypertensive medication, postural change). HD positioning, used in some specialized stroke centers in France, is supported by some physiological and clinical findings. This position has a significant impact on chest‐wall compliance with diaphragm elevation and decreased alveolar expansion, responsible for CO 2 elevation.…”

Head down tilt 15° in experimental intracerebral hemorrhage: a randomized noninferiority safety trial

“…However, this trial has been criticized because it recruited mostly non‐LVO ischemic stroke patients, and positional therapy was applied several hours after symptom onset [20]. Notably, a recent observational study in consecutive LVO acute stroke patients treated with HDT15° for the first 12 h showed better clinical outcome and no adverse events (including hemorrhagic complications, intracranial hypertension, and aspiration pneumonia), compared to standard +30° positioning [7].…”

“…Leptomeningeal collaterals are an independent predictor of outcome even in untreated ischemic stroke patients with large vessel occlusion (LVO), providing residual blood flow to cortical ischemic areas despite persistent occlusion [4]. Recent experimental and clinical studies indicate that head down tilt 15° (HDT15°) increases collateral flow and improves outcome in acute ischemic stroke caused by LVO, by gravitational blood flow diversion from the lower body toward the head, without significant safety concerns [5–8]. HDT15° appears to be an extremely simple, low cost and feasible measure to be applied as a collateral therapeutic in the hyperacute (even prehospital) phase of acute ischemic stroke, prior to recanalization therapies.…”

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“…At the same time, other studies disprove the above described effect on MAP in normotensive individuals (Sibbald et al, 1976;Terai et al, 1995). Moreover, the position was also proposed as a screening tool for the presence of a low cerebrospinal fluid pressure syndrome in daily headache patients (Rozen et al, 2008), as a challenge test in patients with repeated syncope (the Tilt test), or as a method of therapeutic intervention in acute phase of ischaemic stroke (Gauthier et al, 2018), in intensive care or in other surgical situations (Kompanje et al, 2012).…”