Clinical scenario: Patient with stroke comes in with large vessel occlusion and neuro deficits; he was placed supine for CT scan and NIHSS improved. Vascular imaging still shows clot, but deficits are now nondisabling and NIHSS is low. Should you proceed with thrombectomy?
Small study from UCLA used the Heads Up maneuver to select patients who should proceed to thrombectomy.
- stroke within 7.5h onset
- disabling neuro deficit on presentation
- improved while on CT to nondisabling deficit
- evidence (in MRA) of persisting large vessel occlusion
Heads up Maneuver: (performed in angio suite)
- position 90 degrees upright x 30 minutes, monitor BP/HR q5-10mins
- if worsened –> lower to supine, proceed with angio
- if remained stable –> lower to supine or 30 deg HOB; transfer to stroke unit
Pathophysiology of Delayed Collateral Failure:
STROKE –> increased CO / SVR –> improved flow to peri-infarct regions –> MI / CHF / dysrhythmias / sepsis / dysautonomia / drugs –> reduced CPP –> delayed collateral failure –> expansion of core infarct
Head position influences collateral flow by increasing flow velocity in affected MCA. Impaired autoregulation allows perfusion to collateral channels to become passive-pressure dependent. Head flat position increases CPP by 20%, improves neurologic function in 15% of patients. Risk of aspiration PNA with head flat position is <5%.
The study found that heads up maneuver can be used to stress collateral systems and identify those patients who are vulnerable to hemodynamic failure.
- Only 5 patients included in the series – all had high NIHSS on arrival, improved during MRI scanning.
- Two patients tolerated 30 minutes, no thrombectomy performed, had excellent outcome with just medical therapy.
- *Spontaneous recanalization occurred within 72h (assumed that vigorous collaterals promoted recanalization).
- Three patients worsened with manuever and had successful recanalization and excellent outcomes as well.
Ali, L., Weng, J., Starkman, S., Saver, J., Kim, D., Ovbiagele, B., Buck, B., Sanossian, N., Vespa, P., Bang, O., Jahan, R., Duckwiler, G., Viñuela, F. and Liebeskind, D. (2016). Heads Up! A Novel Provocative Maneuver to Guide Acute Ischemic Stroke Management. Interventional Neurology, 6(1-2), pp.8-15.