Recent studies suggest that head-down positioning (HDP) intervention may improve outcomes in ischemic stroke. In the era of reperfusion therapy, a key protective strategy is to administer neuroprotective interventions before recanalization to reduce the loss of the ischemic penumbra, thereby salvaging more penumbral tissue after revascularization and ultimately improving clinical outcomes. Based on this concept, and considering the neuroprotective effects of HDP, the investigators hypothesize that HDP intervention prior to endovascular therapy (EVT) in patients with large vessel occlusion could improve clinical outcomes. This hypothesis is further supported by a recent clinical study (NCT03728738), which demonstrated that compared to a sitting up position (30°), a flat supine position (0°) before EVT significantly reduced the incidence of neurological deterioration prior to the procedure. Building on the above rationale, this trial aims to investigate the efficacy and safety of HDP intervention prior to EVT in patients with large vessel occlusion.
Age ≥ 18 years;
Patients with acute large vessel occlusion scheduled for endovascular thrombectomy within 24 hours of symptom onset;
Baseline National Institute of Health Stroke Scale (NIHSS) ≥ 6;
Expected waiting time from randomization to femoral artery puncture is more than 30 minutes;
Hemorrhagic stroke: cerebral hemorrhage, subarachnoid hemorrhage;
Severe hepatic or renal dysfunction, increase in ALT or AST (more than 2 times of upper limit of normal value), increase in serum creatinine (more than 1.5 times of upper limit of normal value) or requiring dialysis;
Severe hypertension before randomization (systolic blood pressure >185 mmHg or diastolic blood pressure >110 mmHg);
Cardiac insufficiency (NYHA Class ≥II);
Parallel
head down position
Other interventionthe patient is positioned at a -20° Trendelenburg
early neurologic improvement (ENI)
ENI was defined as more than 4-point decrease in NIHSS within 24±8 hours;
proportion of good collateral circulation status
good collateral circulation status was defined as ASITN/SIR grade 3-4.
Change in National Institutes of Health Stroke Scale (NIHSS)
the minimum and maximum values of NIHSS are 0 and 42, respectively; higher NIHSS mean a worse outcome.
Change in National Institutes of Health Stroke Scale (NIHSS)
the minimum and maximum values of NIHSS are 0 and 42, respectively; higher NIHSS mean a worse outcome.
Changes in cerebral infarct volume
infarct volume was measured by MRI-DWI
changes in dynamic cerebral autoregulation (dCA)
dCA data include phase difference (the main parameter, determined as the phase shift angle ranging from 0° to 90°), gain (difference in the amplitude between CBFV and ABP), and the coherence function (indicates signal-to-noise ratio), which is determined according to previous report (Guo ZN, Guo WT, Liu J, et al. Changes in cerebral autoregulation and blood biomarkers after remote ischemic preconditioning.)
changes in cortical oxygen saturation
cortical oxygen saturation is determined by near infrared spectroscopy
changes in serum biomarkers
serum biomarkers include MMP-9, TNF-alpha, IL-1beta, etc.
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