JAMA Neurol

Flat head-of-bed positioning improves pre-thrombectomy stability in stroke patients

June 23, 2025

Flat (0°) head positioning prior to thrombectomy in acute large vessel occlusion (LVO) stroke appears to be a protective strategy for maintaining neurologic stability while awaiting intervention, without increasing pneumonia risk. The findings support consideration of 0° positioning in the pre-thrombectomy phase for eligible patients.

Details: This prospective, randomized, blinded-endpoint trial enrolled 92 adults with anterior or posterior LVO and salvageable penumbra (CT perfusion or ASPECTS ≥6) within 24 hours of onset, all eligible for thrombectomy. Patients were randomized to either 0° (flat) or 30° head-of-bed positioning prior to transfer for thrombectomy, with serial NIHSS monitoring every 10 minutes until catheterization.

Findings: Worsening of NIHSS by ≥2 points before thrombectomy occurred significantly more often in the 30° group compared with the 0° group (hazard ratio [HR], 34.40; 95% confidence interval, 4.65-254.37; P < 0.001). Severe neurologic deterioration (≥4 NIHSS points) was also more frequent with 30° positioning (HR, 23.57; 95% CI, 3.16-175.99; P = 0.002). No cases of hospital-acquired pneumonia were observed. All-cause mortality at 3 months was lower in the 0° group (4.4% vs. 21.7%; P = 0.03).

Source:

Alexandrov AW; ZODIAC Investigators, et al. (2025, June 4). JAMA Neurol. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. https://pubmed.ncbi.nlm.nih.gov/40465238/