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. congestive heart failure) 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.