# ZerO Degree head positioning In Acute ischemiC stroke (ZODIAC)

> **NIH NIH R01** · UNIVERSITY OF TENNESSEE HEALTH SCI CTR · 2021 · $467,219

## Abstract

Positioning of the patient during the immediate “hyperacute” hours after onset of large artery acute
ischemic stroke is an important, yet understudied aspect of nursing care that could impact the course
of treatment and clinical outcome in this most severe form of stroke. Since 1968, clinical symptom
worsening has been documented in this population when the head of bed (HOB) is elevated to 30o or
higher, while clinical improvement or symptom stability has been noted with 0o-HOB positioning.
Mechanisms for 0o-HOB clinical improvement include favorable gravitational blood flow conditions and
recruitment of collateral blood channels, while in the case of treatment with clot-busting medications,
increased blood flow may allow more medication to reach occluded arteries facilitating clot
breakdown. Despite this, there remains a divide within the clinical community about what position is
best. A recent clinical trial (HeadPoST) failed to answer the question of head positioning for
hyperacute large artery stroke patients, enrolling primarily minor, ambulatory strokes with small
perforator artery disease that have never been shown to benefit from 0o-HOB positioning, along with
intracerebral hemorrhage patients; patients were also enrolled late into symptoms (7 hours) beyond
the point where brain tissue salvage is possible. Our team of leading hemodynamic stroke specialists
has shown in our pilot work that blood flow can increase as much as 20% on average in large artery
stroke territories with 0o-HOB positioning, and that elevated intracranial pressure is absent in the
hyperacute phase out to 48 hours from symptom onset. We have also found that pneumonia is rare
with 0o-HOB positioning using our extensively piloted methods. We propose a randomized controlled
trial of head positioning to determine if 0o-HOB positioning during the early hyperacute phase of large
artery ischemic stroke prevents neurological symptom worsening. A novel protocol will be employed
that can be executed within current standard of care requirements for rapid thrombectomy treatment
with or without clot-busting medications (n=182). Patients will be randomized to one of two groups: 1)
0o-HOB positioning; or, 2) 30o-HOB positioning. We hypothesize that optimal HOB position can be
determined by early neurological symptom worsening during the intervention (Aim 1), and propose
that real-time deterioration may be a surrogate measure for decreased downstream perfusion,
potentially impacting viability of brain at risk for infarction. Aim 2 will confirm that use of 0o-HOB
positioning for in large artery ischemic strokes is safe in a larger generalizable population of patients.
Use of this nursing measure holds significant promise as an innovative adjunct method to improve
ischemic stroke symptoms, and ultimately reduce disability.

## Key facts

- **NIH application ID:** 10204114
- **Project number:** 5R01NR017850-04
- **Recipient organization:** UNIVERSITY OF TENNESSEE HEALTH SCI CTR
- **Principal Investigator:** ANNE W ALEXANDROV
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $467,219
- **Award type:** 5
- **Project period:** 2018-09-25 → 2024-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10204114

## Citation

> US National Institutes of Health, RePORTER application 10204114, ZerO Degree head positioning In Acute ischemiC stroke (ZODIAC) (5R01NR017850-04). Retrieved via AI Analytics 2026-06-11 from https://api.ai-analytics.org/grant/nih/10204114. Licensed CC0.

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