Patients from the same unit who had not sufferedfalls were the controls. Data were gathered from the patients’ clinicalhistory and also from the results of a balance test conducted six monthsbefore the study.thirty-one patients were included (10 cases and 21 controls). Intradialyticbody weight change was significantly greater among cases (p <0.05).Patients in the case group also presented greater lateral instability afterdialysis (p <0.05). Other factors such as high blood pressure,antihypertensives, beta-blockers, and lower heart rates were also associatedwith falls.a greater intradialytic weight change was associated with an increase in riskof falls. Nursing staff can control these factors to prevent the incidenceof falls in dialysis patients. In Latin America the prevalence ofpatients treated with hemodialysis (HD) is 451 per millioninhabitants. In thesecircumstances, patients must undergo dialysis several times a week, with the aim ofeliminating uremic toxins and excess fluids, as well as rebalancing theconcentrations of ions and other substances, which affect the body’s homeostasis.These biochemical alterations affect the functioning of organs and systems relatedto balance; in fact, hyponatremia, which affects 6%-29% of patients receivingHD, has been associatedwith an increased risk of falls.Moderate to severe Chronic Kidney Disease (CKD) (stages 3-5) affects 6.8%-9.5% of thepopulation-5, both situations associated with greater morbidity andmortality in patients receiving HD-7.The excess liquid that must be extracted from patients varies depending on the weightgain that they experience in the interdialytic period and the difference betweentheir calculated optimum weight or dry weight, which is defined as weight when thereis no fluid excess or deficiency, without the presence of detectable peripheraledemas, with normal blood pressure, and with no postural hypotension. The excessvolume is removed during dialysis, which lasts about 4 hours. The higher the weightgain, the higher the ultrafiltration rate required, resulting in an increased riskof hypotension during dialysis or postHD orthostatic hypotension-9. Likewise, severe CKD, even whentreated by HD, results in the progressive deterioration of structures involved inbalance. One example is HD-related amyloidosis, which affects joints such as the hip, which plays animportant role in postural control in older adults. In addition, patients treated with HD usuallyhave other comorbidities, which require treatment and in many cases lead to thepolymedication of HD patients, which poses a greater risk of falls.Therefore, HD produces hemodynamic changes and acute homeostasis, affecting posturalcontrol. Previous studies have observed that, after HD sessions, patients sufferchanges in postural control-14. The nursing staff in charge ofour dialysis unit is responsible for connecting, supervising and disconnecting thedialyzed patient. In these processes, clinical situations can occur, which arealready contemplated by protocols, given that greater postural instability isobserved after the sessions. In turn, other subclinical situations possibly relatedto the factors already mentioned continue to pose a risk, which keeps the incidenceof falls high among our patients, at levels similar to those observed in prevalencestudies, in which the incidence was between 1-1.6 falls perpatient-year-16.Consequently, numerous factors may place HD patients’ postural control at risk.Preventing falls in HD patients is essential, because the consequences in terms ofquality of life, associated morbidity and reduction in life expectancy are veryimportantThe aim of this study was to identify possible associations between a higherprobability of falls among hemodialysis patients and the laboratory values,comorbidities, pharmacological treatment, hemodynamic changes, dialysis results andstabilometric alterations.This was a retrospective case-control study with a ratio of 1 case/2 controls,with hemodialysis patients. The STROBE  guide for observational studies wasfollowed, as recommended by the EQUATOR network.The study was conducted in the hemodialysis unit of the Infanta Leonor UniversityHospital (HUIL), in Madrid (Spain), between January and October 2019.The study was conducted with 31 patients: 10 cases and 21 controls matched byage, sex and years receiving dialysis treatment. Patients with prevalent CKDtreated with HD three times a week were included and voluntarily agreed toparticipate in the study. Patients who presented central neurologicalpathologies, vestibular or visual alterations without optical correction,deformations of the locomotor system and those who could not remain standingwere excluded.Patients in the hemodialysis unit who had suffered one or more falls in the last6 months and who reported this in the questionnaires administered monthly by thenursing staff were considered cases (n=10). Thus, the participants were unawarethat the event “fall” was what categorized them as cases in the study. Thecontrols (n=21) were patients from the same unit who did not report falls duringthe study period and they were also blind to this criterion. The nurses who hadcollected the data relative to falls were also unaware of this study.®  to create a database with all the information.Laboratory values, medication, hemodynamic values during the dialysis sessionsand session values obtained by the dialyzer were analyzed. We also evaluated abalance study conducted 6 months earlier in these same patients, using an AMTIAccuGait force platform, previously validated by other study. In this study, each patientunderwent a stabilometry test before (preHD) and immediately after (postHD) thesame dialysis session.After the cases were recruited, the researchers reviewed the patients’ medicalrecords with their prior consent, using IBM’s SPSSThe researchers gathered the following information regarding the generalcharacteristics of the patients: age, sex, body mass index (BMI) and years inrenal replacement therapy.per liter), potassium (mEq/L), calcium(mg/dL-milligrams per deciliter), phosphorus (mg/dL) and beta-2microglobulin protein. The values of the most recent lab tests were considered.All of them were continuous variables.Laboratory variables collected from the patients’ medical records included sodium and heart disease. The number of medications each patienttook simultaneously was counted and categorized according to criteria alreadydescribed in the variable polymedication, which was considered positive if thepatient took 4 or more drugs. These were all dichotomous categoricalvariables.The HD variables recorded by the dialyzer at the start of the study and includedin the analysis were total ultrafiltration (UF), Kt and Kt/v. UF is the fluidremoved from the blood through the dialysis membrane. Kt and Kt/v are measuresbased on the urea kinetic model and have been classically used to express thedialysis dose and to estimate the efficacy of the dialyzer. Kt represents ureaclearance (K) multiplied by the time of HD (t) and Kt/v is Kt divided by thevolume (v) of urea distribution. All these factors were continuous quantitativevariables.Hemodynamic variables collected before and after HD were also analyzed. Thefollowing were recorded: 1) systolic blood pressure (SBP), diastolic bloodpressure (DBP) and pulse pressure; 2) heart rate; 3) dry weight, preHD weightand postHD weight. Changes and differences between preHD and postHD variableswere calculated. All these factors were continuous quantitative variables.. The testswere carried out by two people trained to handle the platform in an officeprepared for this purpose, where the lighting conditions were the samethroughout the day. The variables analyzed were: 1) average displacement rangeof the center of pressure (CoP) on the Y axis (Y range) and X axis (X range)measured in cm (centimeter); 2) maximum and average velocity  of these movements measured in cm/s (centimeter/second); and 3) the areathat included the displacement of the CoP with 95% confidence (Area95) measuredcm2 (square centimeters). All these factors were continuousquantitative variables.The stabilometry variables studied as factors were extracted from a stabilometrystudy conducted with hemodialized patients 6 months prior to this study and allthe patients that composed this sample were included. In this stabilometrystudy, the balance of patients was tested before and after HD, following thesame protocol for all patients, which had been used previously in a similarstudyAfter the database was built, it was cleansed. The Kolmogorov-Smirnov (K-S) testwas used to determine whether continuous variables followed a normaldistribution. The results of the continuous quantitative variables wereexpressed as mean ± standard deviation.2) forqualitative variables. P values <0.05 were considered significant inPearson’s test. The odds ratio (OR) was calculated, in addition to confidenceintervals (CI) at 95%.The comparison of means of the different quantitative factors between the casesand the controls was carried out using the Student’s t-test or the Mann-Whitneytest, according to the distribution presented by the analyzed variables. Thecomparison of the frequency of the different qualitative factors in the case andcontrol groups was performed using the chi-square test  curve was calculatedto obtain the discriminatory cut-off point of the variable difference in weightbetween cases and controls. Youden’s J statistic was calculated to determine theoptimal cut-off point® SPSS Statistics15.0 Inc. Chicago, IL.Statistical analysis was performed using IBM softwareThis study was approved by the Ethics Committee (HUIL-HGUGM) with the title“Balance disorders in patients with chronic kidney disease on hemodialysis(HD)”, under protocol code: HUIL - 18/001; protocol version: 4.5 and versiondate: February 15, 2019.A total of 31 patients, 19 (61.3%) men and 12 (38.7%) women, participated in thestudy. No significant gender differences were found among the cases (6 men and 4women) and the controls (13 men and 8 women). Although there was no difference in the distribution of the polymedication variablebetween cases and controls, we analyzed possible differences in the main groups ofdrugs in terms of falls. The contingency tables for each group and theirsignificance are presented in We analyzed the distribution of HD variables as recorded by the dialysis machine, inaddition to the hemodynamic values of blood pressure, heart rate and weight recordedby the nursing team before and after dialysis. An ROC curve was used to find the discriminatory cut-off point between cases andcontrols in terms of the variable of intradialytic weight change. The area under thecurve was 0.721, with a CI of 95%CI (0.526-0.917). The cut-off point was set at 1.1kg, 1.9 kg and 2.7 kg, which resulted in a sensitivity of 100%, 70% and 40%,respectively and a specificity of 28.6%, 66.7% and 95.2%, respectively. The Youdenindex (J=0.367) indicated that the point that determined the highest sensitivity andspecificity together was 1.9 kg.The controls presented significant differences (p<0.05) in the PreHD and PostHDdata for all the stabilometric variables, except for V x max. In contrast, thedifferences related to HD among the cases were not significant (p>0.05) for anyof the variables.. The session lasts an average of 4 hours, so to remove agreater volume, a higher ultrafiltration rate must be used, which can generate agreater risk of intradialytic hypotension and orthostatic hypotension. Previous studies have related these events withfalls, and this study directly demonstrated that intradialytic weight change is afactor related to the risk of falls. Falls are factors of poor prognosis in patientswho receive dialysis and afterobserving an incidence of falls of 32%, similar to the 37% described in a recentstudy, it would beinteresting to analyze the ability to prevent falls in patients whose intradialyticweight change is greater than 1.9 kg via prevention protocols.This case-control study describes is the first of its kind to describe intradialyticweight change as a factor associated with falls in dialysis patients. The studyshowed that patients in HD who suffer from falls have greater intradialytic weightchanges. When patients arrive at the HD session, they are weighed by the nursingstaff, who determine if there is excess weight relative to their reference weight ordry weight. The greater the weight difference, the greater the volume of liquid thatshould be removed. This usually occurs in patients who do not have good adherence totreatment or dietary guidelines. However, theassociation between postHD heart rate and beta-blocker treatment was notstatistically significant, so this hypothesis was ruled out. It seems likely thatpatients with a limited chronotropic response due to intrinsic or extrinsic causesare at greater risk of falls when undergoing HD.Based on the other results of this study, patients receiving dialysis who fall alsohad significantly lower heart rates after HD than the controls. Physiologically,heart rate is supposed to increase when volemia decreases. If this does not occur,brain perfusion may be affected. The decrease in cardiac stimulus may be due topatients’ medication and in fact, this study found that patients receiving HD andwho fall are more often treated with beta-blockers, which is consistent with thefact that these drugs are included into the group of those that increase the risk offalls andfalls.As for the other drugs analyzed here, all belonging to the group of medications thatincrease the risk of falls, it was observed that patients who fell tookantihypertensives more frequently than those in the control group. These findingsare based on the association between lower preHD blood pressure values and increasedrisk of hypotension, which can affect structures related to motorability such as joints or the central nervous system. In our study, the involvementof these structures was not assessed since they had not been systematically analyzedand were not included in the patients’ medical history. The relationship betweenamyloid deposits and falls has been observed in patients with Parkinson’sdisease. However, todate, a relationship between falls and elevated beta-2 microglobulin ordialysis-associated amyloidosis levels had not been described, at least not in thestudies we found. For this reason, we believe that it is necessary to conductfurther prospective studies to acquire in-depth knowledge about thisrelationship.Regarding laboratory values, dialysis patients with a history of falls had higherlevels of beta-2 microglobulin. Increased levels of this protein are due to thepassing of time in renal replacement therapy: after 15 years receiving HD, about 80%of patients present with dialysis-related amyloidosis; in the present study, patients in the case groupalso had higher velocity of CP movement, but specifically in anteroposteriordisplacements. A previous study found a similar result, describing anteroposteriorvelocity as a fundamental stabilometric variable related to increased risk offalls.On comparing the results of the balance tests of the cases and controls, patients whohad suffered falls presented greater preHD instability than controls. This preHDalteration was observed in the anteroposterior direction and presented significantlyhigher values in terms of the range and velocity of movement of the center ofpressure (CP). These results are similar to those found by other studies thatanalyzed patient balance in between dialysis sessions. A recent study found thathigher velocity of CP movement was associated with falls and it used a similar methodology.Unlike another study whichobserved an increase in postHD lateral range associated with a higher risk of falls,in our study, we found no significant differences between cases and controls inpostHD range and speed of CP movement, although the recorded instability remainedhigher among patients who had suffered falls. The fact that the increased postHDinstability recorded among cases was not statistically significant for any of thestabilometric variables makes us think that the alterations that can result in fallsdo not improve in the periods between sessions. For this reason, future studiesshould determine the circumstances of falls, and whether these patients presenthemodynamic or biochemical alterations in their daily lives more frequently.After dialysis, both cases and controls experienced an increase in the ranges, speedsand area of displacement of the CP, indicating the acute effect of HD on posturalbalance. This effect of HD was consistent with the results of other studyThe results shown here can help underpin a review of disconnection and dischargeprotocols of dialysis sessions, which are the responsibility of a HD unit’s nursingstaff. This line of research could help test protection and surveillance measuresfor at-risk patients and verify their effectiveness in order to avoid falls andtheir consequences.Limitations of this study include mainly its retrospective methodology. The timebetween assessments and the fall that defined the cases varied within the 6-monthperiod considered in this study. Furthermore, the fall that defined a case wasalways outside the hospital and in the period between sessions, but thecircumstances and the exact time of the falls were not taken into account.This case-control study identified some factors that dialysis unit nurses can payattention to in order to reduce the postHD incidence of falls. Patients treated withHD who suffer falls are usually hypertensive, take antihypertensives[angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptorantagonist (ARA II)] and beta-blockers, have elevated serum beta-2 levelsmicroglobulin, and present anteroposterior instability. Unlike the controls, thepatients who had a history of falls presented greater intradialytic weight change.Furthermore, the cases also presented lateral instability and a lower heart rate atthe end of dialysis than the controls.


A retrospective study was performed to investigate the relationship between blood pressure variability (BPV) and imaging features of single small infarction (SSI) on magnetic resonance imaging (MRI).Two hundreds and five patients with SSI and 120 healthy subjects matched with age and sex as the control group were enrolled into this study. All subjects came from the Affiliated Hospital to Qingdao University and Qingdao Municipal Hospital from October 2011 to June 2016. Research subjects were classified into different groups. Blood pressure was measured once a day and recorded during the hospitalization period (7–10 days). The followed up data of patients after discharging from hospital was collected from the follow‐up records.Mean, DSBPMax, DSBPSD, NDBPMax, NDBPSD, and DDBPCV), day‐to‐day, and visit‐to‐visit BPV  in the SSI group were significantly higher than that in control group. Compared with the giant lacunar group, day‐to‐day BPV , and visit‐to‐visit BPV  were significantly higher in the small lacunar infarct group (p < .05). The 24 hr BPV , day‐to‐day BPV , and visit‐to‐visit SBPMax in nonround lesion group were significantly higher than that in round group (p < .05). Compared with nondeep lesion group, some parameters in day‐to‐day BPV and visit‐to‐visit BPV were significantly higher in the deep small lesion group (p < .05).Twenty‐four hours BPV  were related to the SSI characterized by small lesion in deep brain region.Increased BPV parameters such as day‐to‐day and visit‐to‐visit (SBP A retrospective study was performed to investigate the relationship between blood pressure variability (BPV) and imaging features of single small infarction (SSI) on magnetic resonance imaging (MRI). Increased BPV parameters such as day‐to‐day and visit‐to‐visit  were related to the SSI characterized by small in deep brain region. The etiological classification was based on the Chinese Ischemic Stroke Subtype (CISS) classification standard  All cases were confirmed as new infarction (DWI positive and low apparent diffusion coefficient) by cranial MRI; (2) Hospitalized within 3 days after onset, the diameter of cerebral infarction was less than 40 mm in DWI. Exclusion criteria: (1) With obvious stroke sequelae; (2) Large areas of cerebral infarction (complete posterior circulation infarction and over 1/3 anterior circulation); (3) Transient ischemic attack (TIA); (4) Combined intracranial hemorrhage and hemorrhagic transformation after cerebral infarction, infection, and tumor; (5) With severe heart, liver, kidney, and other underlying diseases; (6) Age > 80 years, or with severe dementia or Parkinson's disease and Parkinson's syndrome; (7) Nervous system demyelinating diseases such as Guillain–Barre syndrome, multiple sclerosis, etc.; (8) Disturbance of consciousness. The hospital's institutional review committee on human research approved this study protocol.2.2The severity of neurological impairments of the index stroke was measured using the National Institutes of Health Stroke Scale (NIHSS). NIHSS scores were recorded when patients were admitted to hospital. The risk factors including gender, smoking, alcoholism, hypertension, coronary heart disease, diabetes, fasting blood glucose, and high blood lipids were recorded. The main risk factors were determined as follow: (1) hypertension: antihypertensive drugs before admission or systolic blood pressure > 140 mmHg, or diastolic blood pressure ≥ 90 mmHg after hospital admission; (2) type 2 diabetes: a history of diabetes; fasting blood glucose >7.0 mmol/L or blood glucose 2 hr after meal > 11.1 mmol/L, while glycated hemoglobin >6.5%; (3) hyperlipidemia: past dyslipidemia or abnormalities after hospital admission, total cholesterol > 5.72 mmol/L, TG > 1.72 mmol/L, or LDL > 3.12 mmol/L; (4) Smoking: Currently smoking or quitting smoking (10 sticks/day for 5 years or more (5) Drinking: Daily alcohol consumption > 50ml, abstinence or not drinking).The cranial MRI scan was performed within 72 hr after admission, and GE's superconducting magnetic resonance imaging equipment (model: GE MR Discovery 750 3.0T) was used to obtain T1WI, T2WI, and DWI, 3D‐TOF MRA, and SWI images. The scanning parameters were set as follow: FLAIR‐T1WI ; FRFSE‐T2WI ; DWI‐EPI , or moderate to severe stenosis (≥50%). The lesions of acute cerebral infarction show high signal on DWI, low signal on ADC, and hyperintensity in the FLAIR image. The maximum diameter of the lesion shown by DWI was regarded as the diameter of the lesion. Diameter (d) = 20 mm was regarded as the critical point. Lesion with d < 20 mm is regarded as a small lacuna. For DWI being very sensitive to small lesions, and there is no lower limitation for the lesion diameter. Lesion with 40 mm > d ≥ 20 mm is regarded as giant lacuna. SSI was determined as follow: lesions occur in the cortex, cortex infarcts in the lower half of the oval center and in the coronal, basal ganglia, inner cystic striatum, thalamus, and brainstem regions, regardless of whether the main artery has any degree of stenosis, not considering the size of the lesion . Neurologists and neuro‐radiologists integrated the clinical manifestations and neuroimaging findings, respectively.2.3Max), daytime maximum diastolic pressure (DDBPMax), nighttime maximum systolic blood pressure (NSBPMax), nighttime maximum diastolic blood pressure (NDBPMax), 24 hr systolic blood pressure, 24 hr SBPMean), 24 hr mean diastolic blood pressure (24 hr DBPMean), daytime systolic blood pressure (DSBPMean), daytime diastolic blood pressure (DDBPMean), and mean nighttime systolic blood pressure , nighttime diastolic blood pressure (NDBPMean), daytime systolic blood pressure coefficient of variation (DSBPCV), nighttime systolic blood pressure (nighttime systolic blood pressure)‐coefficient of variation (NSBPCV), daytime diastolic blood pressure coefficient of variation (DDBPCV), nighttime diastolic blood pressure coefficient of variation (NDBPCV), standard deviation of daytime systolic blood pressure (daytime systolic blood pressure‐standard deviation (DSBPSD), nighttime systolic blood pressure‐standard deviation (NSBPSD), day diastolic blood pressure‐standard deviation (DDBPSD), and standard deviation of night diastolic blood pressure . The SBPMean, SBP, DBP, SD, CV, and other parameters were collected. The CV calculation method is CV = 100 × SD/mean.All the followed up data collected from the follow‐up records were analyzed. Twenty‐four‐hour ambulatory blood pressure measurement: in order to minimize the adverse disturbance of hyperacute cerebral infarction on blood pressure, the MC‐6800 ambulatory blood pressure monitoring  was performed after the onset of the disease once every 60 min, continuously monitor the blood pressure for 24 hr.08:00 and 20:00 were set as two time periods of blood pressure monitoring during the day and night. For some patients with acute cerebral infarction who were treated with intravenous thrombolysis after admission, ambulatory blood pressure monitoring was performed 24 hr after admission. The effective SBP measurement ranges from 70 mmHg to 260 mmHg, and DBP 50 mmHg to 150 mmHg. 24 hr effective blood pressure reading >90% is qualified. During hospitalization , blood pressure is measured and recorded every morning. Patients were followed up after discharge. Patients were referred once a month in the outpatient clinic, and blood pressure measurements were taken at rest for 5 min and recorded. Parameters of blood pressure included as follow: daytime maximum systolic blood pressure , baseline MMSE score, vascular risk factors .SPSS 16.0 package for Windows was used for statistical analysis. p < .05 was considered statistically significant.Visit‐to‐visit BPV was quantified by calculating the maximum (Max), standard deviation (SD), coefficient of variation (100 × SD/mean). Measurement data and count data were expressed as mean ± standard deviation (Mean ± SD) and percentage. The 33.1p < .05) between them. There were nonround cerebral infarction in 97 cases (36.5%), round‐like cerebral infarction in 108 cases (63.5%). 122 cases of small lacuna lesions and 83 cases of giant lacunar lesions. According to the distribution of infarction lesions, patients were divided into deep infarction group (130 cases) , and nondeep infarction group (75 cases) . Baseline characteristics of every subgroup showed in the Table A total of 205 patients with SSI were enrolled into this study. The average age was 69.4 ± 10.1) years, of which 113 (55.1%) were male. The average age of the control group including 120 healthy subjects was (68.1 ± 10.8) years, of which 64 (53.3%) were male. The baseline characteristics of the SSI and noncerebral infarction groups are shown in Table 0.1 years3.2x = round lesion (round), y = nonround lesion (nonround), m = small lacunar lesion , n = giant lacunar lesion (giant), p = deep lesion (deep), q = nondeep lesion (nondeep). Figure xmp model , ymp model , xnp model , ynp model , xmq model , ymp model , xnp model , ynp model . Round lesions and deep lesions account for 52.68% and 63.41% in SSI lesions, respectively.In the present study, MRI imaging features of SSI lesion were defined as 3.3Mean, DSBPMax, DSBPSD, NDBPMax, NDBPSD, and DDBPCV in the SSI group were significantly higher in the aspect of 24 hr BPV. There was a statistically significant difference between these two groups . Visit‐to‐visit SBPCV was higher in the SSI group that in the noninfarction group. There was no statistically significant difference between these two groups , but the clinical significance should not be ignored .In the aspect of 24 hr BPV parameters, SBPMax, SBPSD, and SBPCV were statistically significant in the round group and the nonround group (p < .05), and were higher in the nonround group. SBPMean, SBPMax, SBPSD, SBPCV, DBPMean, DBPMax, and DBPSD were statistically significant between the small lacunar lesions group and giant lacunar lesions group. (p < .05), and the above indicators were higher in the small lacunar lesions group. Compared with nondeep infarction group, SBPMean, SBPMax, DBPMean, and DBPMax in deep infarction group were significantly increased, and there was statistically significant between these two groups (p < .05). There were statistically significant differences in SBPMax and DBPMax among these four subgroups. The other parameters were not statistically different among these subgroups (p > .05).In terms of day‐to‐day BPV parameters, SBPMax was statistically significant between the round group and the nonround group (p < .05), and was higher in the nonround group. SBPMean, SBPMax, SBPSD, DBPMean, DBPMax, and DBPSD were statistically significant between the small lacunar lesions group and giant lacunar lesions group (p < .05). Compared with nondeep infarction group, SBPMean and SBPMax were significantly increased in the deep infarction group (p < .05). . Table .3.5Max, SBPSD, and DBPMax.  and visit‐to‐visit BPV  in SSI patients increased significantly compared with that in the noncerebral infarction group. Previous studies had shown that BPV was associated with the recurrence of lacunar infarction , CMBs and enlarged perivascular space, the correlation between different evaluation indexes of BPV with the related diseases are not completely consistent. A number of studies had shown that 24 hr BPV was associated with high white matter signal, and the correlation between BPV and high severity and WMH at different location was not exactly the same  were related to the SSI characterized by small lesion in deep brain region. Of course, this conclusion still needs to be confirmed by prospective studies. In addition to 24 hr average blood pressure, long‐term BPV, blood pressure peak, maximum control of rapid fluctuations should be focus on.This study finds that increased BPV parameters such as day‐to‐day and visit‐to‐visit (SBPNone declared.Putting forward this idea and project administration: Yong peng Yu. Data curation, Methodology: Yong peng Yu, Lan Tan, Yali Zheng and Tingting Jiang. Software and Writing, review and editing: Yong peng Yu and Yali Zheng.https://publons.com/publon/10.1002/brb3.2155.The peer review history for this article is available at


Patients with heart failure (HF) or undergoing cardiogenic shock and percutaneous coronary intervention require short-term cardiac support. Short-term cardiac support using a left ventricular assist device (LVAD) alters the pressure and flows of the vasculature by enhancing perfusion and improving the hemodynamic performance for the HF patients. However, due to the position of the inflow and outflow of the LVAD, the local hemodynamics within the aorta is altered with the LVAD support. Specifically, blood velocity, wall shear stress, and pressure difference are altered within the aorta. In this study, computational fluid dynamics (CFD) was used to elucidate the effects of a short-term LVAD for hemodynamic performance in a patient-specific aorta model. The three-dimensional (3D) geometric models of a patient-specific aorta and a short-term LVAD, Impella CP, were created. Velocity, wall shear stress, and pressure difference in the patient-specific aorta model with the Impella CP assistance were calculated and compared with the baseline values of the aorta without Impella CP support. Impella CP support augmented cardiac output, blood velocity, wall shear stress, and pressure difference in the aorta. The proposed CFD study could analyze the quantitative changes in the important hemodynamic parameters while considering the effects of Impella CP, and provide a scientific basis for further predicting and assessing the effects of these hemodynamic signals on the aorta. P) in the aorta could also be aberrant with the development of HF, causing vascular and arterial remodeling  has exceeded 20 million worldwide, and is increasing at an annual rate of about 2 million people , as life-saving medical devices, have been successfully developed for the HF treatment .To analyze hemodynamics in the aorta quantitatively, analyzing the fluid-dynamic variables is essential. However, traditional strategies using lumped parameter models using via CFD modeling  effectively predicted aneurysm and coarctation of the aorta , in order to better understand the local hemodynamic effects in the aorta. Velocity, WSS, and ΔIn this CFD simulation, blood is assumed to be the incompressible Newtonian fluid. The governing equations for blood flows are set as follows  represents the average velocities, t is the time, xi represents the space coordinates in three-dimensional Cartesian coordinate system, μ is the dynamic viscosity at 0.004 kg/m−1/s−1, ρ is the fluid density at 1,060 kg/m3, where k–ω turbulence model is used for the CFD simulation  is called Reynolds stress term. Since this term is unknown, the shear stress transport  Menter, . The tur Menter, :k and ω represent the turbulent scalar, called turbulent kinetic energy and specific dissipation rate, respectively. Gk is the turbulent kinetic energy produced by laminar velocity gradient, Gω is the turbulent kinetic energy generated by equation (5). Γk and Γω represent the effective diffusion terms of k and ω, respectively; Yk and Yω represent turbulence due to the diffusion.where The enhanced-CT medical image data used in this study were from The First Affiliated Hospital of Dalian Medical University, China. The subject was an 80-year-old man with valve disease and reduced cardiac output. For the image data, the layer spacing is 0.74 mm, and the plane resolution is 512 × 512. This enhanced CT image data were imported into Mimics 21.0 , a medical image processing software, with DICOM  format for data processing and three-dimensional (3D) reconstruction, to acquire a geometric model of the patient-specific aorta. Automatic threshold segmentation and manual separation were used to separate the ascending aorta, brachiocephalic trunk, left common carotid artery, left subclavian artery, descending aorta, and abdominal aorta from other tissues. After smooth processing, the 3D reconstruction model of the aortic arch was obtained while maintaining the original physiological and anatomical characteristics, shown in The 3D structure model of Impella CP drawn with a 3D software, Proe 2.0 , crosssection mesh structure of Impella CP, and the location of Impella CP with its partially enlarged detail are shown in Vin, on the crosssection of blood vessels perpendicular to the direction of blood flow is parabolic, whose contour is shown in The 3D geometric model of the patient-specific aorta was imported into the commercial CFD software package, ANSYS Fluent 2020 R1  for mesh generation. The domain tetrahedral unstructured meshes of about 850,000 elements were established, partly shown in r represents the distance from the approximate center and d represents the approximate diameter calculated based on the area of inlet surface, Vin_mean is the average velocity on the crosssection. The above mathematical expressions for calculating the required waveform of blood flow velocity was written in C-language with user-defined functions (UDFs), which can be compiled and loaded into the fluent library. Zero pressure at the outlet of aorta is prescribed as the outlet condition , In addition, at present, it is difficult to obtain blood flow data in the three branches of aorta such as brachiocephalic trunk, left common carotid artery, and left subclavian artery on the basis of the individual patients with various cardiovascular diseases. Therefore, in this study, the sum of blood flow from the above three branches accounted for 30%  and the sharp geometric changes could easily happen at the bifurcating areas (near A2). Some WSS and pressure waveforms were obtained using the “chart” function in CFD-post of ANSYS Fluent 2020 R1.The semiimplicit method for pressure linked equations pressure–velocity method was used to solve the above fluid governing equations. The spatial discretization schemes of gradient, pressure, and momentum are based on least square cell, standard, and second-order upwind, respectively. Aorta surfaces and walls of Impella CP are set to the no-slip condition. Moreover, in this study, two representative time points 1 and t2  ; however, the computational cost significantly increased when the time step of 0.005 s was used. As a result, a time step of 0.01 s was used in this study and the total calculation time was 30.5 h. In addition, the simulations were conducted for six cardiac cycles to eliminate the initialization effect and achieve stable results. The data during the last cycle was used for analysis  arterial pulsatility. Diminished pulsatility has been associated with adverse events in peripheral blood vessels and other organs, like arteriovenous malformation, hemorrhagic stroke, and damage to other organs such as kidney . Comparatively, WSS in the flow field is related to the blood velocity, which cannot be as high as that at the impeller tip. In general, reduction of WSS within the LVADs is beneficial as it reduces the potential risk of blood trauma, which remains an important clinical concern. In addition, with reference to the ΔP analysis, it is possible to note that ΔP was usually larger than WSS. Especially at t1, the peak systole, blood increased and flowed via the ascending aorta with high ΔP, which expanded the arterial wall due to the compliance of the aorta.As one of the most important hemodynamic parameters, WSS is related to the vascular and arterial adaptation. The simulation results showed that changes in WSS with and without the Impella CP support at two selected representative locations P in This study was still subject to some limitations. For example, these results were specific to one clinical patient-specific aorta data, which ensured that the individual effects of the LVAD support can be analyzed on a patient specific basis. However, global predictions of the LVAD support on aorta required averaging of aortic dimensions on a larger cohort of patients. The aortic model did not consider small aortic branch vessels distal to the aortic arch vessels that can cause additional outflows, and this CFD study did not analyze measures of hemolysis including hemolysis index. Moreover, in this research we only studied the changes in the local hemodynamic effects of aortic arch before and after implanting Impella CP, and zero pressure was used as the outlet condition, implying that the characteristics of downstream vascular system of aortic arch were not considered in the CFD simulation by using the Windkesel model with boundary conditions of proximal resistance and capacitance, and distal resistance , LiaoNing Revitalization Talents Program of China (Grant No. XLYC1807016), and National Institutes of Health R01 grant (Grant No. 1R01HL150346).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study aimed to evaluate the predictors of response to benralizumab therapy in patients with refractory bronchial asthma.After 16 weeks of benralizumab therapy, 32 patients with refractory bronchial asthma were assigned to two groups based on the response to treatment as indicated by changes in the asthma control test score (responders and non-responders) and evaluated for clinical characteristics.Overall, 25 responders and 7 non-responders were identified at week 16. Logistic regression analysis identified a peripheral eosinophil count of >300/μL during benralizumab treatment and a maximal peripheral eosinophil count of >300/μL in the past year as predictors of response.The predictors of response to benralizumab included a peripheral eosinophil count of >300/μL during treatment and a maximal peripheral eosinophil count of >300/μL in the past year. These findings could improve patient selection and reduce medical costs in the future. In recent years, the incidence of allergic diseases has increased globally, and bronchial asthma is a representative allergic disease. Drugs for the treatment of bronchial asthma are mainly inhaled and orally administered. Despite adequate treatment with these drugs, some patients with severe refractory asthma experience impaired quality of life and death in some cases. Recently, various new antibody formulations have been developed and launched for the treatment of asthma. These antibody preparations have displayed excellent therapeutic benefits when combined with traditional anti-asthma medications.However, antibody preparations present some challenges. Although these treatments are expensive, no predictors of response have been established, making it difficult to examine the benefits and drawbacks of antibody preparations and select treatments on the basis of a scientific rationale.®  at our facility, making it an expert facility. We have encountered both benralizumab responders and non-responders in clinical practice.As of June 2019, more than 20 patients have been treated with FasenraThe primary objective of this study was to explore the predictors of response to benralizumab by reviewing response at week 16 in patients with bronchial asthma and comparing blood test data, subjective symptoms, and respiratory function test results before and after the start of therapy between responders and non-responders. The findings from this study will enable the prediction of response to benralizumab and guide the appropriate use of the drug. This will directly correlate with improvements in the quality of medical care for patients with refractory bronchial asthma, thereby effectively reducing medical costs.1 These patients additionally received 30 mg/dose benralizumab, an anti-interleukin (IL)-5 receptor α monoclonal antibody, as a subcutaneous injection (Fasenra®) at weeks 0, 4, and 8 at the Fujita Medical Health University Bantane Hospital between June 2019 and April 2020. In total, 32 patients in the analysis population underwent the asthma control test (ACT), spirography , measurements of fractional exhaled nitric oxide , and blood tests  before treatment with benralizumab. Response to treatment was defined (1) an improvement of ≥3 points in the ACT score or (2) a ≥20% reduction in the OCS dose after 16 weeks of benralizumab treatment. On the basis of the collected clinical information, patients were assigned to one of two groups according to the response to benralizumab, and the clinical characteristics of each group were evaluated.The initial study cohort included 39 patients with poorly controlled refractory bronchial asthma who required continuous treatment with oral corticosteroids (OCSs) despite the administration of high-dose inhaled corticosteroids (ICSs), long-acting β-agonists (LABAs), long-acting muscarinic antagonists (LAMAs), leukotriene receptor antagonists (LTRAs), and sustained-released theophylline, as described in asthma treatment step 4 of the Asthma Prevention and Management Guideline 2018.t-test, as well as univariate analysis using logistic regression.Statistical data analysis was performed using the paired The study protocol was approved by the Fujita Health University Medical Research Ethics Committee (HM19-263).The baseline characteristics of patients are presented in In week 16 of benralizumab treatment, 78% (n=25/2) of patients were responders, and 22% (n=7/32) were non-responders .Relative to baseline, 16 weeks of benralizumab treatment resulted in significant improvements in the ACT score (p<0.001) in responders .Additionally, 16 weeks of treatment resulted in a ≥20% decline in the OCS dose in responders p<0.005, .Logistic regression analysis of responders and non-responders after 16 weeks of benralizumab treatment revealed that a peripheral eosinophil count of >300/μL (p<0.001) during benralizumab treatment and a maximal peripheral eosinophil count of >300/μL (p<0.001) in the past year were predictive of response to the drug .3 Patients with severe refractory asthma experience impaired quality of life and even death in some cases. In recent years, various antibody preparations have been developed and launched for the treatment of asthma. These antibody preparations have displayed excellent therapeutic benefits when combined with traditional asthma medications. Benralizumab, an anti-IL-5 receptor α monoclonal antibody, was approved for marketing on January 19, 2018 and was launched in April 2018. The underlying mechanism of action of this agent involves the induction of natural killer cells through antibody-dependent cellular cytotoxicity, thereby directly and rapidly removing blood eosinophils, and additionally eliminating sputum and airway eosinophils.Approximately 5%–10% of patients with asthma present with severe refractory asthma requiring the concomitant use of drugs such as high-dose ICSs, LABAs, LAMAs, LTRAs, and theophylline, as well as the continuous use of OCSs.4 Although our patients also exhibited a reduced asthma exacerbation rate, this rate was not examined as an indicator of response after 16 weeks of benralizumab treatment in the present study.In the Japanese subgroup analysis of the CALIMA study, the annual asthma exacerbation rate was significantly decreased by 83% by treatment compared with the findings in the placebo group.5 In the present study, the changes from baseline to week 16 of benralizumab treatment included a significant improvement in the ACT score (p<0.001).In the SIROCCO study, the Asthma Control Questionnaire-6 score was significantly improved after 2 weeks.6 Similar results were observed in the current study, and 78% of patients were considered responders according to the aforementioned criteria.In the ZONDA study, the daily OCS dose was reduced by 75% from baseline .7Furthermore, a subgroup analysis of the SIROCCO and CALIMA studies reportedly predicted response in patients with blood eosinophils ≥150/μL and at least two exacerbations per year, and the results of the ZONDA study predicted response in patients on continuous oral steroid therapy with blood eosinophils counts of ≥150/μL.However, in clinical practice, we have encountered both responders and non-responders to benralizumab among patients with poorly controlled refractory asthma despite adequate treatment with inhaled and oral drugs, a high blood eosinophil count, frequent exacerbations, and continuous OCS use. In this study, patients were evaluated at week 16 of benralizumab treatment. As described previously, although antibody preparations are expensive, predictors of response have not been established, thus making it difficult to examine the advantages and disadvantages of antibody preparations or select antibody preparations based on scientific reasoning. Logistic regression analysis of responders and non-responders at week 16 of benralizumab treatment demonstrated the significance of a peripheral eosinophil count of >300/μL during benralizumab treatment and a maximal eosinophil count of >300/μL in the past year to the response to therapy.7In both the SIROCCO and CALIMA studies, benralizumab significantly improved FEV1 in patients with a peripheral blood eosinophil count of ≥300/μL.These results suggest that the maximal peripheral eosinophil count in the past year is a promising indicator of response, in addition to the peripheral eosinophil count during benralizumab treatment. Moreover, the possibility that the peripheral blood eosinophil count at baseline may be lower in patients receiving OCS cannot be eliminated. An improved response to benralizumab could be expected using changes in the peripheral blood eosinophil count during the past year as a reference if feasible.A limited number of studies have investigated predictors of response to benralizumab therapy in patients with refractory bronchial asthma, which was the objective of the present study.Our results indicated that a peripheral eosinophil count of >300/μL during benralizumab treatment and a maximal peripheral eosinophil count of >300/μL in the past year are predictors of response to the drug. In this study, we investigated the predictors of response only at week 16 of benralizumab treatment; hence, the predictors of response to benralizumab need to be further elucidated by prolonging the study duration and increasing the patient sample size. If the results of this study can guide appropriate benralizumab therapy, the quality of medical care afforded to patients with severe bronchial asthma will be improved, and medical costs will be reduced.


Identifying the causes of poor disease control and medication non-adherence is indispensable so that patients can benefit from treatment. The aim of our study was to determine the relationship between parental attitudes, the development of psychological resilience, and systematic medication adherence in a group of adolescents after kidney and liver transplantation. The analysis included the results obtained from 96 families. A total of 52 patients after kidney transplantation and 44 patients after liver transplantation, aged 12–18 years and their parents were examined. The types of parental attitudes were assessed using the Parental Attitude Scale. The patient’s resilience was determined with the Resiliency Assessment Scale. The MMAS-8 was used to assess the regularity of medication-taking behavior. A total of 61% of the patients in the study group displayed high levels of psychological resilience. The analyses showed a positive correlation between resilience and the systematic taking of medication by the patients. Moreover, it was found that the analyzed link between psychological resilience on the degree of the regularity of medication intake was enhanced by a specific type of parental attitude. The obtained results confirm the importance of psychological resources in developing better disease control. The relationship between the type of parental attitudes and medication adherence indicates the need to take into account the family context during the child’s treatment. A particularly important area of research is the issue of cooperation in the course of treatment. In chronic diseases, regular medication intake constitutes the basis of therapy effectiveness and reduces the risk of complications and relapse . AdditioAgainst this background, it is important to undertake research aimed at identifying potential factors that support adolescent patients’ adaptation processes and cooperation in the course of treatment. On the other hand, it is essential to identify disruptive factors in order to adjust them and intervene accordingly.Psychological resilience is mentioned among the various psychological resources facilitating beneficial adaptation to illness. Resilience is revealed in the context of coping with negative life events and difficulties . In thisUndoubtedly, parental attitudes influence the development of psychosocial competences and resources in children. The level of parental emotional commitment and the degree of autonomy granted to the child allow him or her to develop the level of resilience needed to master environmental challenges. The work of Goldschmidt et al. , on the The research based on a meta-analysis  highlighThe present cross-sectional study is a part of a larger work on the psychological determinants of the cooperation of children and adolescents with a chronic illness. The patients were invited to participate in the study during hospitalization or follow-up visit in the clinic. The participation in the study required the patient’s and his or her parent’s informed consent. The study was conducted by a clinical psychologist, with the approval of the bioethics committee.p < 0.05). The mothers of the patients represented 80.2% of the total parental group. The time post-transplantation varied and ranged from 1 to 17 years: for kidney recipients, it was 5 years (2–12) (median and range), and 9 years (2–17) for liver recipients.A total of 96 patients aged 12 to 18 years participated in the study (M = 14.70 SD = 1.836). Among those participating in the study, 52 patients were kidney transplant patients (24 girls and 28 boys) and 44 liver transplant patients (25 girls and 19 boys). Apart from patients, the study also included their parents. One parent per patient participated in this study. Mainly the mothers of the patients participated in the study  by Plopa  was usedThe level of psychological resilience in patients was assessed with the Resiliency Assessment Scale for Children and Adolescents (SPP-18) by Ogińska-Bulik and Juczyński . The scaThe Morisky Medication Adherence Scale MMAS-8 tool was used to estimate the regularity of medication intake, with permission given by the author . It is aThe level of each variable in the study group was characterized using descriptive statistics (mean and standard deviation). A Student’s t-test was used to determine the differences between the level of the studied variables and the values in the general population. For the calculations, the values included in the manual for SPP-18 (2011) were used, which were matched in terms of the characteristics of the group of subjects participating in our study (sex and age concordance). A Student’s t-test was also conducted to determine whether individuals with different disease types differed in the level of the study variables. The next step of the analysis was to perform r-Pearson correlation between the studied variables. Since the study variables were correlated with each other, the next step of analysis was to conduct multivariate regression analysis. The regression analysis allowed for the identification of psychological predictors of medication adherence regularity. Within the regression analysis, a moderation analysis was conducted, where the moderator was parental attitudes, the independent variable was resilience, and the dependent variable was medication adherence regularity. Data included in the regression model were precentered relative to the median. The data presented in the graphs are based on the points determined by the standard deviation values, where a low level of a trait represents -1SD and +1SD refers to high level of a trait. The distribution of variables was tested using the Kolmogorov–Smirnov test. PASW 21  was used for statistical analysis.p = 0.001). Within the whole group, more than half of the subjects under analysis (61.5%) obtained a high level of resilience, 34.4% of the examined adolescents a medium level, and 3.1% a low level. Sex and age differentiated neither the intensity of resilience in the total score nor the individual components and the degree of medication intake. The group of parents displaying an attitude of acceptance was the largest group within the study group, which accounted for 44.3% of the respondents. These were followed by the autonomy attitude (37.91%), excessively protecting attitude (30.26), excessively demanding attitude (27.82%) and inconsequent attitude (20.84%).The mean score obtained by the adolescents in question in the MMAS-8 questionnaire was 6.83, which meant that the regularity of taking medication was at an average level. The average resilience score in the total score for the whole study group of patients was M = 52.67; SD = 9.284. Both the mean of the general resilience score and its four factors were significantly higher than in the normalization group  please keep the comma in F = 2.622, p = 0.22, where for the whole equation, R2 = 0.152. It means that we can predict about 15% of the regularity of taking medication on the basis of the studied variables. However, the increment of the variance of the dependent variable being explained with respect to the previous model was not statistically significant: p = 0.123. The next step of the analysis showed that the regularity of taking medication could also be explained by the type of parental attitude characterized by excessive protectiveness: β = 0.281, p = 0.043. The patients whose parents were more caring and protective showed regularity in taking medication. The mentioned variables, i.e., excessively protective attitude and resilience, explained another part of the variance of the dependent variable, i.e., the regularity of medication intake. The last regression model, additionally including the interaction between resilience level and parental attitudes, was also statistically significant: F (11.94) = 2.545, p = 0.08, where for the whole equation, R2 = 0.252 and the change in R2 was statistically significant: p = 0.05. Of all the interactions included in the aforementioned equation, the interaction between the level of resilience and parental accepting attitude was found to be statistically significant: β = 0.412, p = 0.047. It means that the impact of resilience on the regularity of medication intake is greater the greater the level of acceptance attitude. Thus, there is a synergistic effect. The results are presented in Chronic illness involves difficult experiences and is associated with stress, which is a risk factor for psychosocial development and interference with the child’s daily functioning. For this reason, research is being conducted into factors that buffer stress and have a protective effect in difficult situations . One of Resilience can be treated as psychological resilience, the ease of “recovery” with regard to confronting life’s problems, thereby facilitating positive adaptation to difficult situations. Positive adaptation to illness means having the personal competences needed to implement developmental tasks relevant to each stage. Cohler, Stott, Musick  point toThe importance of family functioning in the process of coping with a child’s illness is pointed out by McCllean and Cohen . ParentsThe results of our study are largely consistent with the ones available in the literature. The regularity of medication intake in the groups of adolescents after kidney and liver transplantation was average. It is interesting to note that the two groups, despite differing in the type of disease and the degree of health and life risk due to graft loss, proved to be homogeneous in terms of the variables studied. In line with the literature, the level of resilience was found to be associated with the regularity of medication intake. A significant association was also found for parental attitudes. An acceptance attitude and an excessively protective attitude were statistically significantly associated with regular medication intake in children. The aforesaid result should be taken with great care because excessive protection is not a desirable parenting style, especially for adolescents, as it implies the assumption of control and responsibility for illness and treatment by caregivers. This, in turn, can create conflict and undermine the teen’s commitment to the treatment process.An attitude of acceptance and recognition of autonomy seems most beneficial at any age. An accepting parental attitude when a child is ill is characterized by the parent’s emotional involvement, providing support and care. The parent focuses on the child, rather than on the illness and own needs. In contrast to the demanding attitude, for example, the parent does not expect the child to take control and responsibility for complying with medical recommendations: taking medication and complying with all treatment requirements. It also does not shift the care of the child to other people or institutions. Rather, it allows the child to gradually assume responsibility for the treatment process according to the child’s developmental capabilities. This attitude enables the child to acquire competence and adapt to the circumstances of a challenging chronic illness.The results of our study showed an association of accepting attitude with resilience of the adolescents studied, which would mean that this style of parenting promotes the development of adaptive competence. Moreover, the above result is relevant to the regularity of medication intake. With adolescent patients’ adherence to medication consistently at an average level, the results of our study take on particular significance. We find that resilience, which is associated with adherence to health behaviors, may be enhanced by external factors, such as parental attitudes.A variety of factors, not just those of the patient, may be responsible for failure in the patient’s treatment process. Interactions should consider the broader context of the situation. The consideration of parental attitudes in the child’s treatment process may be helpful, ultimately saving the patient from exacerbation. In addition, educating caregivers and increasing their awareness of the impact of their behavior on the attitudes and health behaviors of the patients themselves may increase the level of cooperation with the physician.The results of the analysis confirm the significant role of psychological resilience in the process of positive adaptation to the disease and treatment in groups of adolescents after kidney and liver transplantation. It was found that the higher the level of resilience, the greater the regularity of taking necessary medication.The obtained results also indicate the moderating role of certain types of parental attitudes in adherence to pharmacotherapy in adolescents.The relationships revealed in the analysis of the results between the type of parental attitudes and psychological resilience and regularity of taking medication indicate synergistic relationships. In practice, this implies the need to educate caregivers about adolescents taking control and responsibility for treatment outcomes rather than parents.


The criteria for surgical management of ureteropelvic junction obstruction are not well-defined, and there is a risk for loss of renal function before the operation. In this context, certain changes in contralateral kidney had been investigated in order to increase the sensitivity of diagnosis. In this study, we aimed to investigate whether contralateral transient minimal hydronephrosis (CTMH) can be considered as an “early alarm” sign for worsening of the affected kidney in infants with hydronephrosis. A total of 182 infants  with unilateral hydronephrosis were retrospectively analyzed. Ultrasonography and renal scan findings were evaluated. Correlation between the appearance of CTMH, contralateral compensatory hypertrophy (CCH) on ultrasonography, and prognosis of the affected kidney were evaluated.Among the surgically treated patients, 18 (19.6%) patients developed CTMH on average 7 months (0–13 months) before surgery. Among these 18 patients with CTMH, 12 patients (66.6%) had loss of renal function preoperatively, while this ratio was 29.7% on their counterparts (p = 0049). CCH was observed in 31 (33.7%) individuals in surgically treated patient group including all 18 patients with CTMH, while none of the conservatively followed-up patients developed CCH and/or CTMH. In the multiple logistic regression analysis, among the variables investigated, CTMH was found as an independent predictor of the deterioration in the affected kidney and of the poor prognosis . In our study, among the variables investigated, CTMH was found as an independent predictor of the deterioration in the affected kidney and poor prognosis in infants followed-up with isolated unilateral hydronephrosis. Additionally, CTMH can be considered as an “early alarm” sign for worsening of the affected kidney and the need for surgical intervention. Hydronephrosis (HN) is the most common urinary tract pathology detected in the prenatal period. Some of the patients with prenatally diagnosed HN have ureteropelvic junction obstruction (UPJO) and need surgical intervention [1]. As none of the available investigations can make a definite diagnosis of urinary obstruction, differentiation between obstructive (UPJO) and non-obstructive HN is usually made according to clinical findings and anatomical or functional status of affected kidney [2–5]. In this context, changes in the contralateral kidney have also been investigated in order to increase the sensitivity of the diagnosis [6]. In this retrospective study, we described “contralateral transient minimal hydronephrosis” (CTMH) as a new clinical phenomenon and investigated its relation with functional changes in the affected kidney in unilateral hydronephrosis cases.After the approval of the ethics committee, medical records of patients below 1 year of age who were presented with HN between the years 2005 and 2016 were retrospectively reviewed. A total of 182 patients with isolated HN were included. According to treatment, the patients were divided into two groups as surgically-treated and conservatively follow-up patients. All clinical features including age, sex, age of presentation, age of operation, ultrasound examination of the affected and contralateral kidney, and scintigraphy findings were collected from patient files.All patients were evaluated by the Pediatric Nephro-Urology Council  of our hospital. The imaging modalities and timing were discussed and decided individually.For anatomical parameters, detailed US examinations were performed by the same pediatric radiology team, and the same parameters such as HN grade [SFU  grade], renal pelvis anterior-posterior diameter (RPAPD), parenchymal thickness, parenchymal echogenicity, corticomedullary differentiation, uroepithelial thickness had been evaluated and reported. None of the patients were hydrated intravenously before US examinations. The percentile values of the kidneys for evaluating CCH were calculated using Multivariable Pediatric Renal Nomogram based on the studies of Chen et al . Contralateral compensatory hypertrophy was defined as the kidney length above the 95th percentile of normal length according to age, sex, and height. Minimal hydronephrosis was defined as SFU Grade I-II hydronephrosis (RPAPD ranged 5–10 mm) of the contralateral kidney. Minimal hydronephrosis during full bladder and/or which did not persist at the end of the examination was not selected as minimally HN. Contralateral transient minimally hydronephrosis was defined as a minimally HN, which was not present initially, developed during follow-up and regressed by time. Progressive hydronephrosis was defined as an increase in RPAPD and caliceal diameter, parenchymal echo deteriorations, and parenchymal thinning in consecutive ultrasonography examinations.For functional status of the kidneys, Tc-99m DMSA or Tc-99m MAG-3 scintigraphy was performed in selected caseses depending on the severity of HN and clinical symptoms. Although scintigraphy selection used to be determined by the availability of the material and the age of the patient, MAG-3 was preferred in our clinic afterwards. Preoperative DRF < 40% was defined as a decreased renal function. Loss of renal function was defined as >10% loss of DRF in consecutive scintigraphy. At least 10% reduction in DRF and/or deterioration in HN following the operation was identified as postoperative poor outcome.Except for emergency surgical/interventional indications such as severe HN presented with palpable abdominal mass or urinary infection with pyonephrosis, surgical indications for pyeloplasty include progressive HN, loss of renal function and the presence of symptoms during follow-up. Decreased DFR or severe HN alone at clinical presentation did not indicate surgery. t-test and non-parametric variables by Mann–Whitney U test. The homogeneity of variance was determined by the Levene test. To compare qualitative variables, Chi-square test with Fisher exact test correction was used. The Pearson correlation coefficient was used to measure the strength of a linear association between two variables. Forward multiple regression was used for multivariate analysis, which included only variables that reached statistical significance in univariate analysis. The level of statistical significance was set at p < 0.05.Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 22.0 . The Kolmogorov–Smirnov test was performed to assess normal distribution. Parametric variables were analyzed by independent A total of 182  patients with unilateral HN  were included. During follow-up, 92 patients underwent surgical repair of UPJO and unilateral pyeloplasty was performed. Surgical indications of these patients were as follows: progressive HN in 44 patients, loss of renal function in 31 patients, and the presence of symptoms in 17 patients. The median age of patients was 9 (range: 0 – 365 days) days at the time of diagnosis of HN and 7 (range: 6 days–36 months) months at the time of the surgery. The mean postoperative follow-up period was 44.7 (12–99) months for the surgically-treated group.According to clinical and radiologic findigs at diagnosis and during follow-up, 90 patients were treated conservatively, and these patients constituted the follow-up group. The median age of the follow-up group at the time of diagnosis of HN was 4 (range: 5 days–12 months) months. The mean follow-up period was 50.5 (range: 12–72 months) months. Comparative data of these two groups are summarized in Table 1. There was no statistically significant difference between groups in terms of age, sex, side of hydronephrosis, and duration of follow-up.Contralateral transient minimal hydronephrosis was detected in 18 (9.9%) patients during follow-up. The CTMH emerged at the median age of 3 (range: 2–8 months) months and disappeared within an average of 5 (range: 2–10 months) months. Renal pelvis anterior-posterior diameters, SFU grades of these intact kidneys, bladder volume during examination, and RPAPD changes of the affected kidneys before and during this period are shown in Table 2. All these patients were in the surgically treated group . RPAPD in the affected kidney tended to decrease when CTMH was developed (Table 2). A mean of 7 (0–13) months after the emergence of the CTMH, the affected kidney was referred for surgery . Median age at the time of surgery was 10 (5–16) months. None of the patients in follow-up group developed CTMH during a mean duration of 50.5 months. Preoperative loss of DRF rate was 66.6% (12/18) in CTMH (+) patients, while it was 29.7% for the rest of the patients (Table 3). Despite a successful operation , six patients had postoperative loss of DRF (Table 2 and 3).Contralateral compensatory hypertrophy was developed in 31 (17%) patients during follow-up. The CCH was diagnosed at the median age of 9 (range: 2–16) months. The percentile values of the contralateral kidneys at the presentation were 80 and below (5–80), while it was 95 and above (95–100) after compensation. All these patients were in surgically treated group  and 18 (58%) of them were CTMH-detected cases previously. The median time between CTMH detection and CCH development was 5.5 (range: 2–10) months. None of the patients in the follow-up group developed CCH during follow-up.A univariate analysis determined the following risk factors of the deterioration in the affected kidney: CCH and CTMH. In a multiple logistic regression analysis, CTMH was found to be the only independent predictor of deterioration in the affected kidney in the infants followed up with isolated hydronephrosis and poor prognosis  (Table 4).Both anatomical and functional findings of affected kidneys at diagnosis and during follow-up are the main criteria for differentiating obstructive pathologies in prenatal hydronephrosis. On the other hand, obstruction does not only affect the ipsilateral kidney but it also causes significant changes in the contralateral kidney. These changes are the possible result of functional disorders in the affected kidneys, and it is a well-known condition. Hinman termed this condition as a “renal counterbalance” [9]. Renal counterbalance is the response of the contralateral kidney to the reduction of the number of functional nephrons in the affected kidney. Starting from this point of view, it seems logical to consider that various detectable changes in the contralateral kidney might be an indicator of functional changes in the affected kidney. Koff et al. pointed out that CCH can be an early sign of reduced function in the affected, hydronephrotic kidney with obstruction [6]. On the other hand, Brandell et al. reported that CCH was a common finding that might have been manifested without any functional loss in hydronephrotic kidney and should not be used as an auxiliary finding in the follow-up and management of a hydronephrotic kidney [10]. In our series, 31 of 92 patients who underwent surgery had developed CCH on contralateral kidney, while none of the patients, who were followed-up conservatively, developed CCH on serial US exams. All 31 patients with CCH were operated according to our surgical indication criteria, and UPJ obstruction was confirmed by both retrograde urography and operative findings. In addition, CCH was found to be associated with functional defects of the affected kidney (67% of patients) and, in 18 of these patients, there was loss of function preoperatively. Our study also supports the finding that CCH is associated with worsening of the affected kidney (p = 0.0017).transient minimally hydronephrosis”. Although CTHM appears to be a harmless clinical finding, we have documented several clinically significant changes in both affected and contralateral kidneys associated with CTHM. Firstly, all these patients developed CCH on average 5.5 months after the onset of CTMH and CTMH regressed immediately after the development of CCH. Secondly, all patients with CTHM were underwent surgical treatment for UPJO within an average of 7 (2–13 months) months after the emergence of CTMH. Thirdly, all these patients had preoperative renal deterioration on the affected kidney. When we evaluate all these findings, it seems that there is a clinical sequence in some of unilateral HN cases. During the clinical course of these cases, CTMH develops first. Then, CCH emerges, and CTMH disappears shortly after the emergence of CCH. This process is followed by ipsilateral renal failure/loss of function and surgical treatment . There were 18 patients in our series who developed contralateral minimally hydronephrosis during follow-up. The previous examinations of these kidneys did not show any sign of HN and/or calyceal enlargement, neither did the patients hydrated intravenously prior to US investigation. Moreover, all patients had at least one normal ultrasonography report after neonatal period. The median age of the patients at diagnosis of contralateral minimally hydronephrosis was 3 (range: 2–8) months. Since this USG finding was disappeared in all patients within a median 5 (range: 2–10) months period, it was named as “contralateral All these changes can be explained by the effects of partial/chronic urinary obstruction on renal hemodynamics and functions. In guinea-pig models, the renal blood flow of the affected kidney can be halved due to chronic ureteral obstruction [11]. This condition leads to decrease in the number of perfused glomeruli in obstructed kidneys [12]. At the same time, renal blood flow on the contralateral kidney increases while unilateral urinary obstruction occurs. More interestingly, renal blood flow may increase even before any changes are detected in the obstructed kidney [13]. Up to 3 weeks, the number of perfused glomeruli are increased in the contralateral kidney, and this effect is the main reason of hyperfiltration of the nephrons [11]. The filtration rate of the intact/ contralateral kidney increases in proportion to the loss of function in the obstructed kidney. This means that the higher the loss of function of the diseased kidney, the higher the GFR and urine production of the contralateral kidney, which possibly causes minimally HN at the beginning and then results in compensator hypertrophy. Secondary HN caused by increased urine flow and higher pressure in the collecting system is well documented in the literature [14]. This condition is also seen in some cases with nephrogenic diabetes insipidus [15].In our series, patients who developed CTMH and CCH constituted a small proportion of patients treated surgically . The most important question at this point is that why all surgically-treated patients that have proved urinary obstruction did not develop CTMH and/or CCH. Since our study is retrospective, it is not possible to explain this question with our findings. But we may argue that some of CTMH cases were missed because of a short period between the appearance and disappearance of CTMH. This period can meet the period between the follow-up USGs. Another argument might be that the different severity and/or nature of UPJO may determine CTMH development. Among 90 patients in the follow-up group, CTMH was not detected, and all patients with CTMH were underwent surgery. This finding supports that CTMH is closely related with severe urinary obstruction. To the best of our knowledge, CMH was not previously described in the literature and can be the earliest sign of the worsening of the affected kidney. The retrospective nature of the study, the small number of patients with CTMH, and the comparison of different renal functions according to Tc-99m DMSA and MAG-3 data in some patients are the main limitations of this study. Our results need to be strengthened by larger series of patients and prospective studies.In conclusion, the results of our study support the association between the deterioration of the affected kidney and contralateral transient minimal hydronephrosis. Among the variables investigeted, CTMH was found to be an independent predictor of the deterioration in the affected kidney and poor prognosis in infants who are followed-up with isolated unilateral hydronephrosis. Contralateral transient minimal hydronephrosis can predict the gradual loss of DRF on the affected kidney, and, together with clinical and other laboratory findings, it can also predict the need for surgical intervention before contralateral renal injury develops/worsens. This leads us to believe that contralateral transient minimal hydronephrosis can be considered as an “early alarm” sign for both worsening of the affected kidney and the need of surgical intervention.The ethics committee approval from Cerrahpasa Medical Faculty, İstanbul University-Cerrahpaşa was provided for this study (No: A 2016-1). No written informed consent was necessary for this type of study. The data used to support the findings of this study are available from the corresponding author upon request.


The effect of anesthetic management  on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days.We retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds.Of the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome . In addition, an association was found between the number of hypotensive periods and poor functional outcome . No association existed between AUT and functional outcome .Occurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects. Endovascular treatment (EVT) is a highly effective treatment for acute ischemic stroke due to large vessel occlusion –6. NeverEVT can be performed under general anesthesia (GA), conscious sedation (CS), or with local anesthesia (LA) at the site of puncture. The most optimal anesthetic approach during EVT is still a matter of debate since literature shows conflicting results regarding functional outcome –15.One of the differences between GA, CS, and LA concerns procedural hemodynamics. In GA, and to a lesser extent CS, hypotensive periods are relatively common due to administration of anesthetic agents. In LA, these potential detrimental episodes occur less often as anesthetics are avoided. Relevant hemodynamic changes will however be noticed and might therefore be controlled more quickly during GA compared with CS and LA because of the close monitoring.In three single-center, randomized controlled trials, the modified Rankin Scale (mRS) score at 90 days was compared between patients who were treated under GA or with CS –9. Two tThe discrepancies in functional outcome of patients who were treated under GA might be explained by the extent and duration of procedural hypotension depending on hemodynamic management. As in the randomized controlled trials strict protocols for anesthetic blood pressure management were followed, hypotensive periods, and poor functional outcome as a possible consequence, might have been prevented –9. Most In this retrospective, observational study, we aimed to investigate whether hypotension during EVT under GA is associated with functional outcome and risk of complications after EVT in clinical practice.This was a retrospective, observational study of patients treated at two centers; the University Medical Center Groningen (UMCG), between December 2008 and December 2017, and the University Medical Center Utrecht (UMCU), between April 2014 and April 2017. Start of the inclusion periods differed because EVT data were not being stored systemically in the UMCU before April 2014. Both centers serve as a regional comprehensive stroke center and, during the enrollment period, patients were treated under GA as standardized primary anesthetic approach.The study was reviewed by the Institutional Ethical Review Board of the UMCG and approval was waived (reference number: METc 2017/622) as retrospective, observational studies do not fall under the scope Medical Research Involving Human Subject Act . In accordance with national privacy laws during the conduct of the study, informed consent was not required. We consulted the UMCG objections register to inquire whether patients either verbally or in writing refused the usage of their data for research purposes. All study protocols and procedures were conducted in accordance with the Declaration of Helsinki.loket_contract_research@umcg.nl).Data will not be made available to other researchers as no patient approval has been obtained for sharing coded data. Syntax files will be made available from the Loket Contract Research, section of the UMCG’s Department of Legal Affairs, on reasonable request , middle cerebral artery , or anterior cerebral artery , confirmed by computed tomography (CT), and who had a National Institutes of Health Stroke Scale (NIHSS) score of ≥2. EVT had to be initiated within 6 hours after onset of the first symptoms.Exclusion criteria for this study were intubation before arrival at the angiography suite, initiation of GA after start of the intervention, a procedural intracerebral hemorrhage, spontaneous recanalization on the initial digital subtraction angiography run, and technically not feasible EVT, for example due to tortuous arteries or elongation of the aortic arch.Both hospitals performed EVT under GA as part of standard clinical care. Procedural blood pressure was managed according to the Society of Neuroanesthetic and Critical Care guideline. Therefore, it was attempted to maintain the systolic blood pressure (SBP) between 140 and 180 mm Hg, and the diastolic blood pressure (DBP) <105 mm Hg . EVT wasApplication of local urokinase or alteplase was allowed during EVT. In case of high-grade proximal carotid artery stenosis or occlusion, percutaneous transluminal angioplasty, with or without carotid artery stenting, was performed (according to the discretion of the interventionist).Extubation was performed as early as possible after completion of the intervention. Independent of their  ventilation status, patients were all admitted to the intensive care or stroke unit for post-intervention monitoring.Clinical and imaging characteristics were retrieved from non-anonymized EVT registries at both centers. Missing clinical items and hemodynamic parameters were obtained from the patient records. Missing imaging characteristics of patients treated after March 2014 were acquired from the MR CLEAN Registry that included coded data . Data wePeriprocedural hemodynamic values were acquired from 5 minutes before start of induction of GA until extubation in the angiography suite . The SBP, DBP , and heart rate were recorded every 1 or every 5 minutes . These intervals differed because of the method of registration: handwritten anesthesia records were used in the UMCG and digital records were used in the UMCU .The mean arterial pressure (MAP) 5 minutes before induction was set as a baseline value. Hypotension was defined using 2 thresholds because of a lack of a generally accepted definition of hypotension in patients with acute ischemic stroke . They weThe primary outcome was the distribution on the mRS at 90 days after the procedure, a categorical scale  that displays the degree of disability after a stroke .Secondary (safety) outcomes were successful reperfusion, early neurologic recovery, symptomatic intracranial hemorrhage (sICH) within 48 hours after the procedure and in-hospital mortality. Reperfusion was assessed with the modified Thrombolysis In Cerebral Infarction score  after intervention, with a score of ≥2B interpreted as a successful technical result and adequate reperfusion . Early nt test. Continuous non-normally distributed data are reported as the median and interquartile range (IQR) and were compared with the Mann-Whitney U test. Categorical data are reported as number (%) and were compared with the χ2 test.Continuous baseline characteristics were visually assessed for normality using histograms and quantile-quantile plots. Continuous normally distributed data are reported as the mean (SD) and were compared with the independent-sample For both hypotension thresholds (1–2), we studied the association between the four quantifications of hypotension (A-D) and the distribution on the mRS at 90 days. Also, the association between ΔMAP and the distribution on the mRS at 90 days was analyzed. The associations were expressed as adjusted common odds ratios (acORs) derived from multivariable ordinal logistic regression analyses. To adjust for baseline prognostic factors, the model included age, sex, medical history of atrial fibrillation, diabetes mellitus, hypertension, myocardial infarction, and previous stroke, prestroke mRS score, collateral score, NIHSS score at baseline, and time from symptom onset to groin puncture.In all analyses concerning functional outcome at 90 days, mRS scores were reversed, as this more clearly displays a shift toward a better mRS score. This means an (ac)OR >1 reflects a shift toward better functional outcome. Conversely, an (ac)OR <1 reflects a shift toward a worse functional outcome.Associations between the quantifications of hypotension and secondary outcomes were analyzed using binary logistic regression analyses. We adjusted for the same covariates as in the primary analyses.Missing data were imputed using multiple imputations by chained equations based on relevant covariates and outcome. The Last-Observation-Carried-Forward method was used to interpolate missing MAPs. Restricted cubic splines were used to test for nonlinearity.P values are 2 sided, and P < .05 was considered significant. Analyses were performed using R 3.6.1 software  and SPSS Statistics 23.0 software .All Between December 2008 and December 2017 (UMCG) and April 2014 and April 2017 (UMCU), 537 patients with an acute ischemic stroke and large vessel occlusion were treated with EVT. Of these 537 patients, 5 patients objected to the use of their data, 6 had an isolated M3 occlusion, 67 had an occlusion in the posterior circulation, 10 were not treated under GA , and 83 were excluded for various reasons. This left 366 patients to be included in this study .Median age was 70  years, and 202 patients (56%) were male  Tables.For both thresholds, hypotension occurred in approximately half of the patients . Distributions of AUT were right-skewed. Median AUT was 0  mm Hg*min for the absolute threshold and 5  mm Hg*min for the relative threshold. The mean ΔMAP was 35 mm Hg  .Distributions of postprocedural mRS scores at 90 days were equal for patients with and without procedural hypotension .Both occurrence of hypotension and number of hypotensive periods were associated with poor functional outcome . AUT was not associated with functional outcome , neither in a subgroup analysis of patients with procedural hypotension . Correspondingly, hypotension duration was not related to functional outcome .AUT was not associated with functional outcome , neither in a subgroup analysis of patients with procedural hypotension . In addition, no association was found between the three other measures of hypotension and functional outcome .In the univariable regression analysis, an association between ΔMAP and poor functional outcome was found . The association did however no longer exist after adjustment for confounders  .306 of 365 patients (84%) had successful reperfusion, 85 of 347 (24%) showed early neurologic recovery, sICH was seen in 24 of 366 patients (6.6%), and 36 of 366 patients (9.8%) died during hospital admission  Tables. Among patients treated with EVT under GA for acute ischemic stroke, we found that both occurrence of procedural hypotension and an increase in number of procedural hypotensive periods defined by the absolute threshold were associated with poor functional outcome, whereas the extent of hypotension and duration were not.Current guidelines on hemodynamic management during EVT are based on IVT studies and expert opinions due to lack of data. It is recommended to maintain the blood pressure ≤185/110 mm Hg during EVT . DespiteIn a retrospective cohort study including 3 randomized clinical trials , the effect of a procedural MAP below and above certain thresholds on functional outcome was analyzed. Approximately half of the 365 included patients were treated under GA, and the other half under CS. A MAP below 70 mm Hg for more than 10 minutes was found to be associated with poor functional outcome . In a poIn our study, only two of the hemodynamic measures were found to be associated with poor functional outcome. As a consequence, no clear statement can be made about a possible negative effect of low blood pressure. Associations between the other hemodynamic measures and functional outcome might however have been missed due to two reasons. First, the relatively low incidence of procedural hypotension could have led to an underpowered analysis. It seems that anesthesiologists were aware of the possible harmful effect of low blood pressure on a vulnerable brain, resulting in prevention of hypotension. Second, study results might have been confounded by indication. Patients with a worse pre- and consequently post-interventional condition could have been susceptible for hemodynamic instability during GA, for example due to a stronger effect of anesthetic agents. It seems that anesthesiologists anticipated this situation, because of the relatively moderate extent and short duration of hypotension. This might explain the discrepant significance between occurrence of hypotension and increased number of hypotensive periods compared with extent and duration of hypotension.Hypotension was not found to be associated with an increased risk of sICH. We could not compare our results with other studies as these data were not reported. An underlying mechanism could have been a larger infarct core volume and subsequent increased hemorrhagic risk . On the This study has several limitations. First, the baseline blood pressure was based on a single measurement, which increased the risk of a measurement error. In addition, physical stress elevates baseline blood pressure and, therefore, does not correspond with a patient’s average, home-situated blood pressure.Second, in one center, periprocedural blood pressures were recorded in hand written anesthesia records. This may potentially have resulted in less accurate values. Moreover, hemodynamics were measured in relatively large intervals of 5 minutes. To optimize fitting of the curve, a smoothing technique was used, which may have affected the AUT.Third, the influence of infarct location and infarct size could not be determined as these data were not available. This might have led to confounding with the likely direction in favor of the patients without procedural hypotension.Finally, due to the retrospective study design, no study specific anesthetic protocol for blood pressure regulation and pharmacologic guidelines was maintained. Hemodynamics were managed according to recommendations of the Society for Neuroscience in Anesthesiology and Critical Care guideline . As a reOccurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.S1 TableaThreshold was set to a mean arterial pressure value of 70 mm Hg. bSum may not equal 100% due to combined occlusions.A1, anterior cerebral artery, first segment; A2, anterior cerebral artery, second segment; ICA-C, cervical internal carotid artery; ICA-T, internal carotid artery terminus; M1, middle cerebral artery, first segment; M2, middle cerebral artery, second segment; MAP, mean arterial pressure; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale. IQR, interquartile range; n, number; SD, standard deviation. (PDF)Click here for additional data file.S2 TableaThreshold was set to a mean arterial pressure 30% below baseline mean arterial pressure. bSum may not equal 100% due to combined occlusions.A1, anterior cerebral artery, first segment; A2, anterior cerebral artery, second segment; ICA-C, cervical internal carotid artery; ICA-T, internal carotid artery terminus; M1, middle cerebral artery, first segment; M2, middle cerebral artery, second segment; MAP, mean arterial pressure; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale. IQR, interquartile range; n, number; SD, standard deviation. (PDF)Click here for additional data file.S3 TableaMedian modified Rankin Scale score was 3 (2–6). bOdds ratio per 10 mm Hg*min increase. cThreshold was set to a mean arterial pressure value of 70 mm Hg. dThreshold was set to a mean arterial pressure 30% below baseline mean arterial pressure. eOdds ratio per period increase. fOdds ratio per minute increase. hΔMAP was defined as the difference between baseline MAP and single lowest procedural MAP.CI, confidence interval; OR, odds ratio. (PDF)Click here for additional data file.S4 TableaThreshold was set to a mean arterial pressure value of 70 mm Hg. bSuccessful reperfusion was defined as modified Thrombolysis In Cerebral Infarction score of ≥2B. cEarly neurologic recovery was defined as National Institutes of Health Stroke Scale score of 0 or 1 within 24 hours postprocedural, or a decrease of 8 points relative to baseline. dSymptomatic intracranial hemorrhage was defined as parenchymal hemorrhage with early neurologic deterioration .(PDF)Click here for additional data file.S5 TableaThreshold was set to a mean arterial pressure 30% below baseline mean arterial pressure. bSuccessful reperfusion was defined as modified Thrombolysis In Cerebral Infarction score of ≥2B. cEarly neurologic recovery was defined as National Institutes of Health Stroke Scale score of 0 or 1 within 24 hours postprocedural, or a decrease of 8 points relative to baseline. dSymptomatic intracranial hemorrhage was defined as parenchymal hemorrhage with early neurologic deterioration .(PDF)Click here for additional data file.S6 TableaSuccessful reperfusion was defined as modified Thrombolysis In Cerebral Infarction score of ≥2B. bEarly neurologic recovery was defined as National Institutes of Health Stroke Scale score of 0 or 1 within 24 hours postprocedural, or a decrease of 8 points relative to baseline. cSymptomatic intracranial hemorrhage was defined as parenchymal hemorrhage with early neurologic deterioration . dThreshold was set to a mean arterial pressure value of 70 mm Hg. eOdds ratio per 10 mm Hg*min increase. fThreshold was set to a mean arterial pressure 30% below baseline mean arterial pressure.CI, confidence interval; OR, odds ratio. (PDF)Click here for additional data file.S1 FigThe dark blue line represents continuously measured mean arterial pressure (MAP) during endovascular treatment. Area under the threshold (A) was calculated as the total area between (1) an absolute threshold of MAP 70 and procedural MAP, and (2) baseline MAP and procedural MAP of 30% below baseline MAP. ΔMAP (B) was calculated as the MAP at baseline minus the lowest single MAP during endovascular treatment.(TIF)Click here for additional data file.S2 FigaDefined as an impossibility of reaching the intracerebral occlusion (mostly due to tortuous arteries or elongation of the aortic arch).CS, conscious sedation; EVT, endovascular treatment; GA, general anesthesia; LA, local anesthesia; M3, middle cerebral artery, third segment. (TIF)Click here for additional data file.S3 FigmRS, modified Rankin Scale. Number of patients are displayed as percentages.(TIF)Click here for additional data file.