Q: During the acute phase of ischemic stroke (in the first 24 hours) - given there is no risk for aspiration, hemodynamic instability or of increased intracranial pressure - the head of the bed should be kept 

A) 0 - 15 degree 
B) 30 - 45 degrees
C) 90 degrees
D) reverse trendelenburg
E) it does not matter


Answer: A

 During the acute phase of ischemic stroke (in the first 24 hours) - given there is no risk for aspiration, hemodynamic instability or of increased intracranial pressure - the head of the bed should be kept 0 - 15 degrees.  This is best on the hypothesis that cerebral perfusion is maximal when patients are in the horizontal position, as well as to reduce the effect of stenotic vessels and to maximize the collateral flow. But, it should be done after considering all clinical risks particularly aspiration and increased intracranial pressure. Early mobilization and rehab. should be the goal once acute phase is over. Actually, early mobilization during acute phase  (first 24 hours) may be harmful.


References:

1. Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke 2002; 33:497. 

2. Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Neurology 2005; 64:1354. 

3. AVERT Trial Collaboration group, Bernhardt J, Langhorne P, et al. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015; 386:46.