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ARTICLES: Anne W. Wojner-Alexander, Zsolt Garami, Oleg Y. Chernyshev, and Andrei V. Alexandrov Heads down: Flat positioning improves blood flow velocity in acute ischemic stroke Neurology 2005; 64: 1354-1357 [Abstract] [Full text] [PDF]

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Reply to de Paula

Anne W. Wojner-Alexandrov, PhD, RN, CCRN, FAAN   (23 May 2005)

Heads down: Flat positioning improves blood flow velocity in acute ischemic stroke

Wladimir K de Paula, MD   (23 May 2005)

Reply to de Paula 23 May 2005
Anne W. Wojner-Alexandrov, PhD, RN, CCRN, FAAN, Assistant Professor of Neurology & Neuroscience Critical Care Medicine University of Texas - Houston, Medical School, 6431 Fannin, MSB 7.044, Houston, TX 77030 Send Correspondence to journal: Re: Reply to de Paula Anne.W.Wojner{at}uth.tmc.edu Anne W. Wojner-Alexandrov, PhD, RN, CCRN, FAAN	Acute stroke patients may show some clinical improvement in neurologic dysfunction when placed flat, but the question for how long this position should be maintained remains unclear. We individualize the approach to positioning, and some patients are kept in a flat position for the first 24 hours following admission. We emphasize rotation from side-to-side for these patients to minimize risk of aspiration. For patients with concurrent cardiopumonary compromise (e.g. CHF) that do not tolerate flat positioning, we utilize 15-degree head elevation. We have not systematically evaluated use of the Trendelenburg position, but basic physics would suggest that this position may further augment mean flow velocity. Lastly, we consider patients with fluctuating presentation for blood pressure, volume augmentation, or both and this practice is best guided by thorough systemic hemodynamic assessment to avoid fluid volume overload or significant left ventricular afterload promoting cardiac failure. We agree that follow-up studies are needed to determine long-term benefit.
Heads down: Flat positioning improves blood flow velocity in acute ischemic stroke 23 May 2005
Wladimir K de Paula, MD, Dpt of Neurology Sarah Network of Rehabilitation Hospitals SMHS Qd 501 Bloco A - Brasília - DF - 70834030 - Brazil Send Correspondence to journal: Re: Heads down: Flat positioning improves blood flow velocity in acute ischemic stroke wladimir.kummer{at}bsb.sarah.br Wladimir K de Paula, MD	I read with great interest the article by Wojner-Alexander et al regarding down head positioning promoting higher flow velocities in median cerebral artery (MCA). [1] The authors should provide the information regarding the length of the effectiveness of this positioning. By ensuring a higher velocity, there may be more blood coming toward the cerebral tissue, but should all the blood volume be coming out? Increasing cerebral blood volume content may later increase intracranial pressure (ICP) but this was not assessed within the observation period. Further studies are needed to confirm the safety of this procedure. If this ultimately proves effective, lying down will certainly be part of acute stroke measures when acute stroke patients are admitted. Reference 1. Wojner-Alexandrov A, Garami Z, Chernyshev OY, Alexandrov AV. Heads down: Flat positioning improves blood flow velocity in acute ischemic stroke Neurology 2005; 64: 1354-1357.