HeadSOAR: Does a Neutral Trial Support Flexible Rather Than Equivalent Head Positioning After Thrombectomy?

Agreement: I Agree Body: Dear Editor HeadSOAR addresses an evidence gap in current AHA/ASA guidance, which provides no definitive recommendation on head positioning after successful thrombectomy.1 Its neutral result is therefore practice-relevant: it challenges routine 30–40° elevation and supports clinical flexibility, but it does not establish equivalence. The adjusted genOR (1.12, 95% CI 0.97–1.29) still permits a clinically meaningful benefit, and no minimal clinically important difference (

BMJ

By AnonymousSeptember 19, 2026South Africa

Agreement: I AgreeBody:

Dear Editor

HeadSOAR addresses an evidence gap in current AHA/ASA guidance, which provides no definitive recommendation on head positioning after successful thrombectomy.1 Its neutral result is therefore practice-relevant: it challenges routine 30–40° elevation and supports clinical flexibility, but it does not establish equivalence. The adjusted genOR (1.12, 95% CI 0.97–1.29) still permits a clinically meaningful benefit, and no minimal clinically important difference (MCID) was prespecified for the ordinal primary endpoint.

Several reporting limitations constrain guideline inference. Conditional power was not reported despite observed functional independence far exceeding assumptions; inverse probability of treatment weighting (IPTW) diagnostics are lacking; the 90-day mortality analysis excluded patients lost to follow-up (682 vs 676 analysed; 3 vs 7 lost), warranting sensitivity analyses; and exploratory subgroup signals were not adjusted for multiplicity.

I recommend that the authors report MCID considerations, conditional power, IPTW diagnostics, and sensitivity analyses for missing mortality data; present subgroup findings strictly as hypothesis-generating; and clarify that “individualized positioning” denotes clinical flexibility based on neutral efficacy and safety findings, not formal non-inferiority. In guideline terms, HeadSOAR supports flexibility rather than a fixed positioning strategy,2 not replacing one fixed strategy with another. Its value is real but bounded: it weakens a routine rather than proving interchangeability. It should stimulate phenotype-specific research, not a recommendation that the two positions are equivalent.

References

Yuan Z, Peng J, Gu L, et al. Head positioning after endovascular therapy for acute stroke due to large vessel occlusion (HeadSOAR): multicentre randomised controlled trial. BMJ 2026;394:e100363. doi: 10.1136/bmj-2026-100363 [published Online First: 20260820]
Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke 2026;57(8):e316-e436. doi: 10.1161/STR.0000000000000513 [published Online First: 20260126]

No competing Interests: YesThe following competing Interests: Electronic Publication Date: Saturday, September 19, 2026 - 08:45AI use: No, I have not used AIHighwire Comment Subject:

Head positioning after endovascular therapy for acute stroke due to large vessel occlusion (HeadSOAR): multicentre randomised controlled trial