In patients who had acute ischaemic stroke with successful reperfusion after thrombectomy, maintaining an elevated head position appears to have no substantial benefit on 90-day functional outcomes when compared with a flat head position.
“The smaller than expected difference in results between the two groups leaves open the possibility of a modest but clinically meaningful benefit of head elevation in these patients,” the researchers said.
A total of 1,368 adults (median age 68 years, 41.3 percent women) with acute ischaemic stroke caused by anterior circulation large vessel occlusion were included in this study. They were randomized to maintain either an elevated head position (30‒40°, n=685) or a flat head position (0‒10°, n=683) for 72 h after endovascular thrombectomy.
Functional status at 90 days after randomization was the primary outcome, assessed by shift analysis of scores on the modified Rankin scale (range 0‒6), while all-cause mortality was the primary safety outcome. The researchers conducted efficacy analyses using the randomized, full analysis set and safety analyses using the safety population.
Of the participants, 1,358 (99.3 percent) completed the 90-day follow-up. The median National Institutes of Health Stroke Scale score at baseline was 15, and the median 90-day modified Rankin scale score was 3 in the elevated head position group and 3 in the flat head position group (adjusted odds ratio, 1.12, 95 percent confidence interval [CI], 0.97‒1.29; p=0.14). [BMJ 2026;394:e100363]
Ninety-day all-cause mortality occurred in 125 (18.3 percent) of 682 patients in the elevated head elevation group and 137 (20.3 percent) of 676 in the flat head position group (adjusted risk ratio, 0.86, 95 percent CI, 0.69‒1.07; p=0.18).
“Our findings support consideration of a more individualized approach to head positioning following endovascular thrombectomy,” the researchers said.
Head positioning strategy
Earlier studies and physiological rationale suggested potential benefits of flat head positioning, but these data were obtained from patients with nonlarge vessel occlusion stroke or those with large vessel occlusion stroke who had not yet undergone reperfusion, according to the researchers.
“Our results indicate that strict enforcement of a single head positioning strategy after endovascular thrombectomy may not be required to achieve favourable functional or safety outcomes,” they said.
The restored cerebral autoregulation and improved blood flow following a successful recanalization could explain the neutral primary outcome, as suggested by physiological studies. [J Neurol Neurosurg Psychiatry 1976;39:385-391; N Engl J Med 1968;279:307-311]
“Future studies should further investigate whether head elevation confers benefit in subgroups of patients with complete reperfusion and/or larger infarcts (ASPECTS 0-5), given the biological plausibility related to cerebral haemodynamics,” the researchers said.
“Patients who undergo full reperfusion are less likely to benefit from any collateral flow augmentation associated with a flat head position, whereas head elevation may enhance venous return and help optimize cerebral perfusion pressure in patients with early or subclinical cerebral oedema,” they added.
The current randomized clinical trial was conducted cross 67 comprehensive stroke centres in China between 16 November 2023 and 23 January 2025.