Before Stroke Thrombectomy, Keep the Bed Flat, Trial Says
— Tilting the head of the mattress up within the course of early window in titanic vessel occlusion hurts outcomes
by
Crystal Phend, Contributing Editor, MedPage This day
February 7, 2024
PHOENIX — For titanic vessel occlusion (LVO) acute ischemic stroke patients deliberate for mechanical thrombectomy, mattress positioning made a enormous distinction in scientific worsening, the ZODIAC trial confirmed.
Maintaining the head of the mattress flat at a nil-stage attitude after the CT scan while looking forward to the cath lab led to 50-fold fewer cases of early neurologic worsening when put next with the conventional 30-stage attitude. The rate of NIH Stroke Scale (NIHSS) ranking boost of no longer decrease than 2 parts within the course of that duration used to be fair appropriate 2.22% with the zero-stage head put when put next with 55.32% within the heads-up neighborhood (P<0.001), reported Anne Alexandrov, PhD, ANVP-BC, of the University of Tennessee Successfully being Science Middle in Memphis.
The quantity important to harm with the 30-stage tilt used to be fair appropriate 1.88, Alexandrov declared to alive to applause on the leisurely-breaking session of the American Stroke Association’s Global Stroke Conference.
Ninety-day mortality used to be greater within the 30-stage positioning neighborhood as neatly (21.74% vs 4.44%, P=0.03).
“We have now identified a stable put to put patients by which would possibly maybe maybe well be candidates for thrombectomy,” she stated. “That is under no circumstances a remedy for stroke — these patients wish to head to the lab and be treated. However, we would argue that exercise of zero-stage positioning will seemingly be one amongst the largest first steps in managing a titanic vessel occlusion patient. When you get that CTA [CT angiography] affirmation, keep the head of [the] mattress down.”
The implications are mighty extra excessive for patients who come at a neatly being facility with out ability for thrombectomy and will seemingly be transferred, she urged.
Positional cerebral ischemia has lengthy been infamous, with Alexandrov’s neighborhood having beforehand shown a 20% boost in cerebral blood bolt with the rush in hyperacute LVO with flat positioning.
“Or no longer it’s miles a with out a doubt spirited affirmation of what the clinicians have lengthy stated, that put issues,” commented Jeffrey Saver, MD, of the University of California Los Angeles.
He infamous that failure of zero-stage positioning within the simpler HeadPoST trial from 2017 would possibly maybe maybe well also had been due to enrollment of an unselected ischemic stroke population. “And you’d only inquire patients with titanic occlusions, collateral dependent, to display shroud an pause,” stated Saver, who used to be no longer all in favour of ZODIAC, which he stated “very smartly looked on the apt patients and confirmed scientific intuition.”
The trial incorporated 92 beforehand unprejudiced-dwelling adults with LVO strokes deliberate for mechanical thrombectomy remedy at 12 taking part hospitals from 2018-2023.
The inclusion standards had been traditional of a patient being chosen for thrombectomy within the course of the behold duration, Alexandrov stated. Exclusion standards incorporated evolving malignant infarction that will maybe well build randomization to zero-stage positioning unsafe or laborious to tolerate.
All patients had been scored with the NIHSS while on the CT scanning mattress at zero degrees, then randomized to a straight away alternate to 30-stage mattress positioning or to remain flat. Investigators stayed with the patient the total time to be slump there used to be no alteration within the put from project.
Along with repeat NIHSS scoring each 10 minutes, a closing NIHSS ranking used to be finished by a protocol naive-practitioner straight sooner than the patient used to be moved to the cath lab desk for thrombectomy.
Enrollment stopped early due to efficacy. Even though the COVID-19 pandemic introduced a field, only one patient used to be misplaced to phrase-up, Alexandrov infamous.
The secondary endpoint of NIHSS deterioration of no longer decrease than 4 parts had equivalent outcomes, with a 40.3 share level advantage to laying flat (2.22% vs 42.55%, P≤0.001) and a quantity important to harm of two.forty eight.
Among the safety endpoints, neatly being facility-obtained pneumonia or other pulmonary deterioration — one amongst the well-known rationales for maintaining the head of the mattress elevated in traditional neatly being facility practice — did no longer occur in both neighborhood, although the trial used to be underpowered for scientific events.
“Within the fast time window between arrival and cath lab, the danger of aspiration is decrease than over several days,” Saver infamous, “so the long-established nursing put for several days of care is rarely any longer necessarily the one we want to exercise within the acute duration.”
The next step will seemingly be to behold head positioning within the pre-neatly being facility arena, Saver urged. “It’s miles something that will maybe well also no doubt be with out verbalize applied within the ambulance … Within the ambulance, you’re going to have some patients who’ve hemorrhage, who’re going to be progressing, who will seemingly be extra at risk for aspiration. So it be an originate inquire, but it with out a doubt would possibly maybe maybe well also neatly also be priceless there.”
Disclosures
Alexandrov and coauthors disclosed increase by the National Institute of Nursing Learn.
Saver has reported consulting and/or advising to Medtronic, Stryker, Cerenovus, and Snappy Clinical. His institution also has patent rights in mechanical thrombectomy units for stroke.
Predominant Supply
Global Stroke Conference
Supply Reference: Alexandrov A “Zero stage head positioning in acute titanic vessel ischemic stroke” ISC 2024; Summary LB 1.