Elevated Head Positioning Before Thrombectomy Linked to Worse Outcomes

According to study results published in JAMA Neurology, for people undergoing mechanical thrombectomy as treatment for large vessel occlusion (LVO) stroke, a supine head positioning at 0° in the period preceding the procedure may provide better outcomes than an elevated head positioning at 30°. Whereas an elevated head position was linked to increased clinical worsening, the findings of the phase 3 ZODIAC clinical study (NCT03728738) demonstrate the potential role of prethrombectomy head position in determining patient outcomes.

The prospective, randomized, ZODIAC clinical trial was conducted across 12 hospitals in the continental United States from 2018 to 2023 and included a total of 92 individuals with ischemic stroke and LVO with favorable parenchymal imaging. Participants were randomly assigned 1:1 to a 0° (n=45) or 30° (n=47) head position in the period before undergoing mechanical thrombectomy. The primary end point was early neurologic deterioration before thrombectomy, defined as a ≥2-point worsening in National Institutes of Health Stroke Scale (NIHSS) score. Researchers recorded patient outcomes every 10 minutes before the initiation of thrombectomy, at 24 hours, at discharge day or day 7, and at 3 months. 

• 1 participant in the 0° head elevation group experienced early neurologic deterioration vs 26 individuals in the 30° group (hazard ratio [HR], 34.40; 95% CI, 4.65 to 254.37; P<.001).
• 1 participant in the 0° head elevation group showed a ≥4-point worsening in NIHSS score vs 20 of those in the 30° group (HR, 23.57; 95% CI, 3.16 to 175.99; P=.002).
• Over the 90-day study period, there were 2 all-cause deaths (4.4%) in the 0° group and 10 (21.7%) in the 30° group (P=.03).
• 24 hours after thrombectomy, 39 individuals in the 0° group (86.7%) and 28 in the 30° group (59.6%) showed improved NIHSS score at time 0 (odds ratio [OR], 0.24; 95% CI, 0.08 to 0.68; P=.01).
• NIHSS score improvements were sustained in 39 individuals (86.7%) in the 0° group and 31 individuals (66.0%) in the 30° group at discharge day or day 7 (OR, 0.32; 95% CI, 0.11 to 0.92; P=.03)
• At 90 days, 31 participants in the 0° group (68.9%) and 26 in the 30° group (56.5%) showed a modified Rankin Scale (mRS) score of ≤2 (OR, 0.59; 95% CI, 0.25 to 1.39; P=.22).