Head Position Matters in Stroke Care Before Thrombectomy

Medscape

18-06-2025

A flat 0° head positioning before thrombectomy was associated with a significantly less risk for early neurologic deterioration and all-cause mortality than a conventional 30° head elevation in adults with large vessel occlusion (LVO) stroke, a new study showed.
METHODOLOGY:
Researchers conducted the prospective, multicenter ZODIAC trial from 2018 to 2023 with 92 patients (mean age, 67 years; 52% men). All had LVO stroke confirmed on CT angiography and a viable penumbra and were eligible for thrombectomy within 24 hours of stroke.
Participants were randomly assigned to receive either 0° (n = 45) or 30° (n = 47) head-of-bed positioning before thrombectomy.
National Institutes of Health Stroke Scale (NIHSS) scores were assessed every 10 minutes until thrombectomy began.
The primary endpoint was early neurologic deterioration, defined as a worsening of ≥ 2 NIHSS points before thrombectomy. Additional outcomes were severe neurologic deterioration (worsening of ≥ 4 NIHSS points) before thrombectomy, hospital-acquired pneumonia, and all-cause death within 3 months.
TAKEAWAY:
Early neurologic deterioration was more common in the 30° group than in the 0° group (55% vs 2%; hazard ratio [HR], 34.4; P < .001), as was severe neurologic deterioration (n = 20 vs n = 1; HR, 23.6; P = .002).
< .001), as was severe neurologic deterioration (n = 20 vs n = 1; HR, 23.6; = .002). The all-cause mortality rate at 90 days was significantly lower in the 0° group than in the 30° group (4% vs 22%; P = .03).
= .03). A greater proportion of patients in the 0° group than in the 30° group showed neurologic improvement at 24 hours post-thrombectomy (87% vs 60%; odds ratio, 0.2; P = .01).
= .01). No participant in either group developed hospital-acquired pneumonia.
IN PRACTICE:
'Results suggest that patients awaiting thrombectomy treatment for LVO stroke should be positioned with the head at 0° to ensure clinical stability and prevent worsening,' the investigators wrote.
'We posit that 0° head positioning is a bridging maneuver to thrombectomy, protecting ischemic tissue and possibly reducing infarct progression before definitive treatment,' they added.
SOURCE:
This study was led by Anne W. Alexandrov, PhD, University of Tennessee Health Science Center, Memphis, Tennessee. It was published online on June 04 in JAMA Neurology .
LIMITATIONS:
This study was limited by its small sample size and early termination, the lack of blinding to head position, and the exclusion of data on thrombectomy decisions. Additionally, patients transferred between facilities were excluded, which may have affected the 3-month outcomes.
DISCLOSURES:
Funding was provided by the NIH. Several investigators reported receiving a grant or per-patient payment from NIH during the study. One also reported being a paid co-investigator on the NIH grant for imaging core lab services. Full details are listed in the original article.