72 hours of head elevation did not significantly improve 90 day functional outcomes versus flat head positioning in patients who had acute ischaemic stroke from large vessel occlusion with successful reperfusion after thrombectomy.
Key Findings
Results
Elevated head position (30-40°) did not significantly improve functional outcomes at 90 days compared with flat head position (0-10°) after successful endovascular thrombectomy.
Primary outcome was functional status at 90 days assessed by shift analysis of scores on the modified Rankin Scale (mRS).
Median 90-day mRS score was 3 (IQR 1-5) in both the head elevation group and the flat head position group.
Adjusted generalised odds ratio for a lower level of disability was 1.12 (95% CI 0.97 to 1.29, P=0.14).
1368 adults were randomised 1:1 across 67 comprehensive stroke centres in China between November 2023 and January 2025.
The trial was a multicentre, prospective, randomised, open label, blinded endpoint clinical trial.
Results
All-cause mortality at 90 days was numerically lower in the elevated head position group but did not reach statistical significance.
All-cause mortality occurred in 125 (18.3%) of 682 patients in the elevated head position group versus 137 (20.3%) of 676 patients in the flat head position group.
Adjusted risk ratio was 0.86 (95% CI 0.69 to 1.07, P=0.18).
All-cause mortality at 90 days was the primary safety outcome.
Methods
The study population had a median age of 68 years with a median baseline NIHSS score of 15, reflecting a severely affected stroke population.
1368 adults aged ≥18 years were enrolled; median age was 68 years.
565 participants (41.3%) were women.
Median baseline National Institutes of Health Stroke Scale (NIHSS) score was 15.
All participants had acute ischaemic stroke caused by anterior circulation large vessel occlusion with successful reperfusion defined as an expanded thrombolysis in cerebral infarction (eTICI) score ≥2b after endovascular thrombectomy.
1358 of 1368 patients (99.3%) completed the 90-day follow-up.
Methods
The head positioning intervention was maintained for 72 hours after endovascular thrombectomy, with patients assigned to either 30-40° elevation or 0-10° flat positioning.
Participants were randomly assigned 1:1 to elevated head position (30-40°, n=685) or flat head position (0-10°, n=683).
The intervention duration was 72 hours post-thrombectomy.
Efficacy analyses used the randomised full analysis set; safety analyses used the safety population, which was identical to the randomised population.
Adjusted models included age, baseline NIHSS score, baseline Alberta Stroke Programme Early Computed Tomography Score, occlusion site, and time from last known well to randomisation.
Conclusions
The authors noted that the smaller than expected difference between groups leaves open the possibility of a modest but clinically meaningful benefit of head elevation.
The adjusted generalised odds ratio of 1.12 favoured head elevation but did not reach statistical significance (P=0.14).
The authors explicitly stated that '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 trial was registered at ClinicalTrials.gov (NCT06115707).
What This Means
This research examined whether the angle at which a stroke patient's head is positioned after a clot-removal procedure (endovascular thrombectomy) affects recovery. Researchers randomly assigned 1,368 stroke patients across 67 hospitals in China to either have their head elevated at 30-40 degrees or kept flat at 0-10 degrees for 72 hours after their procedure. All patients had successfully had their blocked artery reopened. The study found no statistically significant difference in disability levels or survival between the two groups at 90 days — both groups had a median modified Rankin Scale score of 3, indicating moderate disability.
In terms of survival, 18.3% of patients in the elevated head group died within 90 days compared to 20.3% in the flat head group, but this difference was also not statistically significant. The primary outcome of functional status, measured by a shift analysis across all levels of disability on the modified Rankin Scale, showed a slight numerical trend favoring head elevation (adjusted odds ratio 1.12), but this did not meet the threshold for statistical significance (P=0.14).
This research suggests that for stroke patients who have had successful clot removal, simply elevating the head to 30-40 degrees for three days does not produce a clearly detectable improvement in recovery compared to keeping the head flat. However, the authors note that the results do not entirely rule out a small but potentially meaningful benefit of head elevation, and this question may warrant further investigation. The findings are relevant to routine stroke unit care, where head positioning is a simple, low-cost intervention.
Yuan Z, Peng J, Gu L, Hu F, Li G, Li J, et al.. (2026). Head positioning after endovascular therapy for acute stroke due to large vessel occlusion (HeadSOAR): multicentre randomised controlled trial.. BMJ (Clinical research ed.). https://doi.org/10.1136/bmj-2026-100363