Head positioning in suspected patients with acute stroke from prehospital to emergency department settings: a systematic review and meta-analysis.

Aim: This study aimed to clarify whether the lying-flat position from prehospital to emergency department settings more effectively improves neurological outcomes of patients suspected with acute stroke over the sitting-up position.

Methods: We searched PubMed, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for published randomized controlled trials until September 2019. The study population included patients suspected with acute stroke from prehospital to emergency department settings. We compared outcomes between the lying-flat position and sitting-up position groups. The critical outcome was the modified Rankin Scale score at 90 days, and important composite outcomes were 90-day mortality, pneumonia recurrence, and recurrent ischemic stroke. The certainty of evidence of the outcome level was compared using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Results: In total, 881 studies were identified from the databases, and two randomized controlled trials were included in the analysis. The pooled risk ratio of 90-day modified Rankin Scale score was not statistically significant (risk ratio 0.86; 95% confidence interval [CI] 0.56-1.32) between the lying-flat position and sitting-up position groups. When comparing the 90-day mortality, pneumonia occurrence, and recurrent ischemic stroke, no significant differences were observed between the two groups. Risk ratio was 1.00 (95% CI 0.87-1.14), 0.90 (95% CI 0.74-1.11), and 0.81 (95% CI 0.14-4.64) for 90-day mortality, pneumonia occurrence, and recurrent ischemic stroke, respectively.

Conclusion: This study suggests that the lying-flat position is not more effective than the sitting-up position in terms of 90-day modified Rankin Scale score in patients suspected with acute stroke.