Comparing nursing students and AI systems performance on the ability to solve basic life support and advanced cardiac life support multiple choice exam questions.

Selective aortic arch perfusion vs. conventional advanced cardiac life support: a bi-ventricular pressure-volume loop analysis in a swine model of cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) is a time-sensitive emergency associated with high mortality and substantial risk of neurological disability. Extracorporeal cardiopulmonary resuscitation (ECPR) using extracorporeal membrane oxygenation (ECMO) has been introduced for refractory cardiac arrest, but recent randomized controlled trials have reported conflicting results, and the benefit of ECPR implemented according to rigorously timed protocols remains uncertain. This trial evaluates whether emergency total extracorporeal life support (ECLS), with emphasis on expedited cannulation and active left ventricular (LV) unloading, improves 30-day survival with favourable neurological outcome compared with standard advanced cardiac life support (ACLS) with rescue ECLS in adults with refractory shockable out-of-hospital cardiac arrest. This is a prospective, investigator-initiated, multicenter, open-label randomized clinical trial conducted in eight experienced extracorporeal membrane oxygenation (ECMO) centers in the Taipei metropolitan area. Eligible adults aged 18-75years with witnessed refractory shockable OHCA (ventricular fibrillation or pulseless ventricular tachycardia) who received bystander cardiopulmonary resuscitation (CPR) are randomized 1:1 on emergency department (ED) arrival. Participants are assigned to: (1) emergency total ECLS, with initiation as soon as possible after randomization and within 60min of the emergency call, or (2) standard ACLS with rescue ECLS, in which at least 15min of standard ACLS is provided in the ED before ECLS is considered. Both groups receive immediate coronary angiography and percutaneous coronary intervention (PCI) when indicated, and active LV unloading is recommended according to prespecified criteria. Survival at 30days with favorable neurological status, defined as a Cerebral Performance Category score of 1 or 2. The ECLS-OHCA trial will provide complementary randomized evidence on the impact of expedited time-to-flow and protocolized LV unloading on neurological outcomes in refractory shockable OHCA and will explore the cost-effectiveness of this strategy. ClinicalTrials.gov:NCT06692075.

The Utstein Formula for Survival, the ethos of the American Heart Association's 2025 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, is a conceptual model for survival of out-of-hospital cardiac arrest that equally weighs medical science, educational efficiency, and local implementation. With this formula in mind, the American Heart Association has put forth new guidelines that emphasize not only high-quality chest compressions and early defibrillation but also robust systems of care, equitable access, advanced resuscitation techniques, and postcardiac arrest recovery. The 2025 updates carry significant weight for health policy, clinical practice, education, and ethical discussions. In this review, we highlight the major changes, discuss their implications, and propose directions for future research and implementation.

This quality improvement initiative aimed to address nursing retention in the emergency department (ED) at The Ottawa Hospital by providing accessible, in-house advanced cardiovascular life support (ACLS) training. The program sought to reduce barriers to certification, increase job satisfaction, and improve clinical confidence. Funded through an Ottawa Hospital strategic plan initiative, 16 subsidized ACLS courses were offered over 2years (2023-2024), including both full courses and recertifications. The program utilized a blended learning model, combining online modules with hands-on, ED-specific scenarios facilitated by local ED physicians. A total of 172 nurses completed the program. Participants were surveyed to assess the program's impact on retention, job satisfaction, and confidence in ACLS skills. Among 65 survey respondents (40.4% response rate), 73% reported that the program was important to their decision to remain in the ED, while 69% felt more valued by the organization. Participants reported increased confidence in ACLS skills (92%), with 98% rating the hands-on practice as sufficient for skill development. Course satisfaction was high, with 98% rating the program as excellent or good, and 83% strongly preferring the blended learning model as compared to the traditional didactic course. Qualitative feedback highlighted the program's role in reducing barriers to professional development and enhancing preparedness for critical care scenarios. The in-house ACLS program at The Ottawa Hospital was associated with higher self-reported nursing retention, job satisfaction, and skill confidence while addressing logistical and financial barriers to ACLS certification. Feedback on the blended learning model and ED-specific scenarios was highly positive. This program serves as a model for other institutions seeking to implement similar initiatives to enhance nursing retention.

Patient: Female, 61-year-oldFinal Diagnosis: Cardiac arrest • ceftriaxone induced anaphylaxisSymptoms: Anaphylaxis • cardiac arrestClinical Procedure: —Specialty: AllergologyObjective: Rare diseaseBackgroundCeftriaxone is a cephalosporin antibiotic administered by injection, and although it is widely used, there have been rare reports of anaphylaxis and cardiac arrest, with some fatal outcomes. This report describes the case of a 61-year-old woman with anaphylaxis and cardiac arrest on initial intravenous administration of ceftriaxone who recovered following cardiopulmonary resuscitation.Case ReportA 61-year-old woman with a 3-day history of cough and dizziness presented to the emergency room. She had been taking cefuroxime and aminophylline, with no known antibiotic allergies. On examination, mild leukocytosis was observed, and chest computed tomography (CT) revealed right lower-lobe consolidation, consistent with pneumonia. Intravenous ceftriaxone was administered. Within 30 seconds, she developed severe respiratory distress and cyanosis. Ceftriaxone was immediately discontinued, and she rapidly progressed to asystole, and advanced cardiovascular life support (ACLS) was initiated. Spontaneous circulation was restored after 2 minutes. She stabilized with corticosteroids and supportive care and her respiratory status and oxygenation improved. One hour after onset, a transient truncal urticaria occurred and resolved spontaneously. She was then transferred to the intensive care unit (ICU) and discharged in good health after 3 days. No complications were noted at 1-month follow-up.ConclusionsAn initial intravenous dose of ceftriaxone may trigger rare but serious anaphylactic reactions, even in patients without a history of drug allergy, underscoring the need for vigilant monitoring during administration.

This study introduces AutoCLC, an AI-powered system designed to assess and provide feedback on Closed-Loop Communication (CLC) in professional learning environments. CLC, where a sender’s Call-Out statement is acknowledged by the receiver’s Check-Back statement, is a critical safety protocol in high-reliability domains, including emergency medicine resuscitation teams. Existing methods for evaluating CLC lack quantifiable metrics and depend heavily on human observation. AutoCLC addresses these limitations by leveraging natural language processing and large language models to analyze audio recordings from Advanced Cardiovascular Life Support (ACLS) simulation training. The system identifies CLC instances, measures their frequency and rate per minute, and categorizes communications as effective, incomplete, or missed. Technical evaluations demonstrate that AutoCLC achieves 78.9% precision for identifying Call-Outs and 74.3% for Check-Backs, with a performance gap of only 5% compared to human annotations. A user study involving 11 cardiac arrest instructors across three training sites supported the need for automated CLC assessment. Instructors found AutoCLC reports valuable for quantifying CLC frequency and quality, as well as for providing actionable, example-based feedback. Participants rated AutoCLC highly, with a System Usability Scale score of 76.4%, reflecting above-average usability. This work represents a significant step toward developing scalable, data-driven feedback systems that enhance individual skills and team performance in high-reliability settings.

While the immediate goal of cardiopulmonary resuscitation is to achieve return of spontaneous circulation, the patient-centered goal is to minimize neurological injury. Several medications used during cardiac arrest have been associated with poor neurological outcomes. For patients cannulated for veno-arterial extracorporeal membrane oxygenation during cardiac arrest, termed extracorporeal cardiopulmonary resuscitation, the patient-centered impact of these medications has not yet been described. We conducted a retrospective Extracorporeal Life Support Organization registry-based analysis. The primary outcome was cerebral performance category (CPC) score at hospital discharge. Cumulative odds models assessed the association between either (1) binary receipt of a medication or (2) the number of epinephrine milligrams given, and CPC score. The model reports the probability of having a score lower than each CPC level. To minimize bias in the receipt of advanced cardiovascular life support drugs, we used inverse probability treatment weights. Antiarrhythmics were associated with better neurological outcomes (amiodarone: CPC ≤ 1 [odds ratio [OR], 1.28 [95% CI, 1.00-1.65]; P=0.048] and CPC ≤ 2 [OR, 1.38 [95% CI, 1.06-1.78]; P=0.015]; lidocaine: CPC ≤ 1 [OR, 1.69 [95% CI, 1.32-2.17]; P<0.001], CPC ≤ 2 [OR, 1.82 [95% CI, 1.39-2.38]; P<0.001], CPC ≤ 3 [OR, 1.76 [95% CI, 1.30-2.40]; P<0.001]). Intraarrest sodium bicarbonate administration resulted in a lower likelihood of a CPC < 2 to 3 (CPC ≤ 2 [OR, 0.63 [95% CI, 0.49-0.81]; P<0.001], CPC ≤ 3 [OR, 0.65 [95% CI, 0.49-0.86]; P=0.003]). There was no significant difference in CPC score among adults who received intraarrest calcium. The unweighted cumulative effects model demonstrated a dose-dependent increasing relationship between epinephrine doses and harm for all CPC levels (OR, 0.89-0.94; P<0.001 for all). Our data support that increasing doses of epinephrine and nonantiarrhythmic advanced cardiovascular life support medications both worsen the probability of neurologically intact survival for patients who undergo extracorporeal cardiopulmonary resuscitation.

Emergency medical services (EMS) represent a critical intersection of public safety and healthcare, where the efficiency of first responders can determine life or death outcomes. In the Philippines, the Bureau of Fire Protection (BFP) is tasked with providing these vital services, especially in rural areas like Sipocot, Camarines Sur, where healthcare access is often limited. This study assessed the capabilities and expertise of BFP-Sipocot personnel through a mixed-methods approach, utilizing inventory assessments, semi-structured interviews, and focus group discussions to evaluate training, resources, and infrastructure. The findings reveal significant challenges that hinder effective emergency response. Personnel have attended only six out of sixteen essential training indicators, leading to identified gaps in specialized knowledge and skills. Quantitatively, the station faces severe resource limitations; for instance, there is a total absence of equipment for advanced cardiac life support and a critical shortage of basic life support and personal protective equipment. Perhaps most significantly, the study found a complete absence of ambulances at the BFPSipocot station, which directly delays the transport of victims to hospitals and places lives at risk. Furthermore, while standard operating procedures (SOPs) for trauma and medical emergencies are documented, they remain non-operational. The research concludes that the delivery of EMS in Sipocot is currently insufficient due to limited training, inadequate physical facilities, and a lack of essential life-saving vehicles. To improve public safety outcomes, it is recommended that BFP-Sipocot personnel undergo specialized training in areas such as advanced cardiac life support and ambulance operations. Additionally, the study emphasizes the need for a stronger partnership with the Local Government Unit (LGU) to secure necessary funding and ensure that emergency management protocols are fully operationalized.

Enhancing Outcomes Through High-Fidelity Advanced Life Support Education: An Interdisciplinary Approach to Implementation and Quality Improvement.

BackgroundHealth care professionals must stay updated with the latest guidelines for basic life support (BLS) and advanced cardiac life support (ACLS) to effectively assist patients during cardiac emergencies. Since its launch in 2018, the Ghana Heart Initiative has significantly enhanced the skills and knowledge of health care professionals in managing cardiovascular diseases, including cardiac emergencies.ObjectiveThis study aims to assess the knowledge and skills of BLS and ACLS among health care professionals immediately after training in Ghana.MethodsThis cross-sectional, training-based study involved 541 and 302 health care professionals trained in BLS and ACLS, respectively. Among them, 229 BLS and 124 ACLS-trained participants completed the questionnaires immediately after the training, and their data were included in the final analysis. Knowledge was assessed using a standardized questionnaire and an instructor-led skills evaluation based on the updated 2018 and 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.ResultsThis study shows that 74.6% (171/229) of the health care professionals had adequate knowledge and skills in BLS. Those working in tertiary health care facilities were 80% less likely (adjusted odds ratio [AOR] 0.20, 95% CI 0.07-0.59; P=.003) to have adequate BLS knowledge and skills than those in primary health care facilities. Health care professionals from regions such as Volta and Oti were 4.94 times more likely to have adequate BLS knowledge and skills compared to those from Bono East (AOR 4.94, 95% CI 1.17-20.80; P=.03). Over 73.3% (91/124) of health care professionals had adequate knowledge and skills in ACLS. Males were 7.05 times more likely (AOR 7.05, 95% CI 2.69-18.46; P<.001) than females to possess adequate ACLS knowledge and skills.ConclusionsGiven an opportunity to learn and practice, health care professionals in Ghana attain adequate knowledge and skills in BLS and ACLS.

While potential risks for limb ischemia have been explored in studies of venoarterial extracorporeal membrane oxygenation (ECMO), they remain inadequately defined for patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). We identified risk factors for the development of lower limb ischemia during ECPR using a large nationwide ECPR cohort. A post hoc analysis was conducted using a nationwide, multicenter, retrospective study (Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan II [SAVE-J II]). Thirty-six institutions from 2013 to 2018. Adult patients who underwent ECPR for out-of-hospital cardiac arrest. None. Lower limb ischemia was defined as the requirement for a therapeutic distal perfusion catheter (DPC), fasciotomy, or amputation. Risk factors for lower limb ischemia were assessed using multivariate logistic regression models that included patient characteristics, ECPR-related information, and resuscitation content as potential confounders. Of the 969 patients, 72 (7.4%) developed lower limb ischemia. No significant differences were observed regarding background characteristics, cannulation location, puncture method, or venoarterial ECMO catheter size between patients with and without limb ischemia. However, a prophylactic DPC was less frequently employed in patients with lower limb ischemia than in those without (4 [5.6%] vs. 219 [24.4%]; p < 0.001). Higher incidences of cannulation-related bleeding and cannula malposition were observed in patients with limb ischemia than in those in patients without limb ischemia (22 [30.6%] vs. 162 [18.1%]; p = 0.009 and 9 [12.5%] vs. 29 [3.2%]; p < 0.001, respectively). Multivariable analyses revealed that prophylactic DPC placement was associated with a lower risk of limb ischemia (0.20 [0.07-0.55]; p = 0.002), whereas cannulation-related bleeding and cannula malposition were linked to an increased risk of lower limb ischemia (1.83 [1.06-3.14]; p = 0.030 and 3.81 [1.68-8.64]; p = 0.001, respectively). Lower limb ischemia during ECPR would be anticipated in patients with cannulation-related complications, and prophylactic DPC placement may be considered to mitigate the risk of lower limb ischemia.

Wearable sensing technologies incorporated into virtual reality (VR) headsets can provide a number of unique, previously hidden insights into individual and team learning and performance in complex environments. However, the most impactful and efficient mechanisms for conveying multimodal data (e.g., gaze, mental workload, etc) allowing for unique insights are not well understood. This study used a human-centered design process to develop and evaluate a multimodal debriefing dashboard. Twelve Advanced Cardiac Life Support (ACLS) Instructors completed VR cardiac arrest simulations and participated in interviews and design thinking workshops to identify dashboard features, leading to high-fidelity mock-ups and an interactive prototype. A second group of 6 ACLS instructors then evaluated the prototype by providing mock feedback on simulation performance with and without the dashboard in a pre-post format, followed by surveys assessing usability, acceptability, appropriateness, feasibility, trust, and perceived accuracy. The final prototype dashboard features a video, a timeline of clinical actions, automatic error identification, mental workload, and visual attention data. It also generates closed-loop communication reports on a separate webpage. The evaluation study showed that participants provided performance analysis and feedback to students when using the dashboard, targeting specific (non)technical skills aligned with ACLS learning objectives. Participants rated the dashboard highly, with a System Usability Scale score of 88.9%, reflecting above-average usability. An interactive multimodal debriefing dashboard prototype was developed using a user-design framework with prototyping and iterative feedback. Use of the dashboard resulted in improved evaluation and debriefing practices targeting learning outcomes, with participants rating the dashboard favorably. This dashboard has the potential to enhance simulation-based learning by offering near real-time analytics that promote a deeper understanding of individual and team technical and nontechnical skill acquisition and mastery.

We describe full neurologic recovery from an out-of-hospital cardiac arrest with a prolonged arrest time (35 min) and prehospital interval (12 h) from the Antarctic continent after the use of standard advanced cardiac life support (ACLS) protocols and thrombolytic therapy. A 61-year-old male had a witnessed collapse in the dining facility at McMurdo Station, Antarctica, resulting in prompt activation of emergency services. The responding firefighter team found the patient in ventricular fibrillation and administered defibrillations. After the defibrillations, the responding team transported the patient to the base clinic. Clinic staff in the resuscitation bay achieved return of spontaneous circulation (ROSC) after successful defibrillation and medication administration. The postarrest electrocardiogram (EKG) showed that an anterior ST-elevation myocardial infarction was the cause of the ventricular fibrillation. Clinic staff administered tenecteplase, and the patient was prepared for transport to New Zealand. The patient was transported aboard an LC-130 aircraft with a transport time of 7 h. The total time from cardiac arrest to arrival at the receiving hospital was 12 h. On arrival to definitive care, the patient underwent percutaneous coronary intervention revealing 100% occlusion of the left anterior descending artery. The vessel was opened and 2 drug-eluting stents were placed. Remarkably, the patient survived the arrest completely neurologically intact. This case highlights the effectiveness of the current ACLS algorithms and chain of survival despite austere locales and long transport times.

Advanced Cardiac Life Support Compliance and Outcomes in In-Hospital Cardiac Arrests: A Prospective Observational Study

The American Heart Association and the American Academy of Pediatrics provide these pediatric advanced life support guidelines focusing on resuscitation during cardiopulmonary resuscitation and emergency cardiovascular care. These guidelines are intended to be a resource for health care professionals to identify and treat infants and children up to 18years of age (excluding newborn infants) in the prearrest, intra-arrest, and post-cardiac arrest states as well as select other emergency care situations. These guidelines apply to infants and children in various settings, including the community, prehospital environments, and hospital environments. Topics presented include ventilation and advanced airway strategies during cardiopulmonary resuscitation; drug administration and weight-based dosing of medications during cardiopulmonary resuscitation; energy doses for defibrillation; measuring cardiopulmonary resuscitation physiology and quality; extracorporeal cardiopulmonary resuscitation; post-cardiac arrest care related to management of core temperature, blood pressure, oxygenation/ventilation, neurologic monitoring, and seizures; neurological prognostication post-cardiac arrest; post-cardiac arrest survivorship; family presence during cardiopulmonary resuscitation; evaluation of sudden unexplained cardiac arrest; management of shock types; airway/intubation management; arrhythmia management including bradycardia and tachycardia (narrow and wide complex); treatment of myocarditis/cardiomyopathies; resuscitation of patients with single ventricle congenital heart disease; management of pulmonary hypertension; and management of traumatic cardiac arrest. Lastly, important gaps in resuscitation science knowledge are identified, aiming to encourage further scientific inquiry and provide additional evidence for future pediatric advanced life support guidelines. Key Words: AHA Scientific Statements • cardiopulmonary resuscitation • child • epinephrine • heart arrest • pediatric • prognosis.

Codeveloped by the American Heart Association and the American Academy of Pediatrics, this publication presents the 2025 guidelines for basic life support during cardiopulmonary resuscitation and emergency cardiovascular care of the pediatric patient, excluding the newborn infant, and represents the first comprehensive update of treatment recommendations since 2020. Incorporating the results of structured evidence reviews from the International Liaison Committee on Resuscitation, these guidelines are for lay rescuers and health care professionals with recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. Existing guidelines remain relevant unless specifically updated in this publication. Topics reviewed include the initiation of cardiopulmonary resuscitation; pulse check; components of high-quality cardiopulmonary resuscitation; chest compression technique; support surfaces for cardiopulmonary resuscitation; opening the airway; coordination of shock and cardiopulmonary resuscitation; types of defibrillators or automated external defibrillators; defibrillator paddle or pad size, type, position; treatment of inadequate breathing with a pulse; and foreign-body airway obstruction. Key topics that are new, are substantially revised, or have significant new literature include the elimination of 2-finger chest compressions in infants due to ineffectiveness of achieving proper depth with a recommendation of 1-hand or 2 thumb-encircling hands technique; the immediate application and use of an automated external defibrillator with a pediatric attenuator if available for cardiac arrest; and in infants with severe foreign-body airway obstruction repeated cycles of 5 back blows alternating with 5 chest thrusts (no abdominal thrusts), and in children with severe foreign-body airway obstruction repeated cycles of 5 back blows alternating with 5 abdominal thrusts. Key Words: AHA Scientific Statements • cardiopulmonary resuscitation • chest compressions • defibrillator • foreign body airway obstruction • heart arrest • shockable rhythm • ventilation.

The guidelines in this document from the American Heart Association and the American Academy of Pediatrics focus upon optimal care of the newborn infant, including those who are proceeding to a normal transition from the fluid-filled uterine environment to birth. Newborn infants who are proceeding to normal transition can benefit from deferred cord clamping for at least 60seconds in most instances, skin-to-skin with their parent soon after birth, and appropriate assistance with thermoregulation. Some newborn infants require assistance during transition, with interventions ranging from warming and tactile stimulation to advanced airway management, assisted ventilation, oxygen therapy, intravascular access, epinephrine, and volume expansion. In this context, individuals, teams, and health care settings that care for newborn infants should be prepared and have access to appropriate training and resources for neonatal resuscitation. The newborn chain of care provides guidance on considerations that may lead to optimal outcomes for newborn infants starting from prenatal care to recovery and follow-up. Key Words: AHA Scientific Statements • cardiopulmonary resuscitation • laryngeal mask • neonatal resuscitation • neonate • oxygen • umbilical cord management • ventilation.

Simulation learning is widely used in nursing education to improve clinical competence and emergency preparedness. In Advanced Cardiac Life Support (ACLS), simulation provides nursing students with realistic scenarios to enhance decision-making, teamwork, and technical competencies. This scoping review aimed to explore: (1) the learning experiences of nursing students participating in ACLS simulation and (2) the barriers to its implementation in nursing education. Although numerous studies support the effectiveness of simulation, there remains limited synthesis on how nursing students learn through ACLS simulations, the challenges involved, and the outcomes achieved. These methods used a scoping review that followed the Joanna Briggs Institute guidelines and the PRISMA flowchart. English-language articles published between 2015 and 2025 were retrieved from three electronic databases. Five studies met the inclusion criteria and were critically appraised using the Quality Assessment with Diverse Studies (QuADS) tool. A total of five studies met the inclusion criteria and were included in the review. Three overarching themes emerged: (1) learning processes encompassing cognitive, psychomotor, and non-technical skills development; (2) student experiences characterized by increased confidence and emotional growth; and (3) barriers such as emotional distress, limited team communication, and technological constraints. These findings show that ACLS simulations provide valuable experiential learning but require supportive facilitation. The Conclusion ACLS simulation significantly supports the learning experience of nursing students, improving clinical judgment, skills, and confidence. However, barriers, including emotional strain, communication challenges, and limited institutional resources, must be addressed to ensure effective implementation and sustained learning outcomes. Recommendation is that educators should promote emotional safety, structured debriefing, and ensure equitable access to simulation resources to maximize the learning outcome.

BACKGROUNDThe 2015 as well as the 2020 cardiopulmonary resuscitation guidelines have stressed that high‐quality cardiopulmonary resuscitation increases the survival rates of patients suffering from nonshockable cardiac arrest. However, whether the management of adult patients with out‐of‐hospital cardiac arrest (OHCA), performed in accordance with the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) 2015, is associated with favorable neurological outcomes remains unknown. The present study aimed to study the relationship between the implementation of the CoSTR 2015 clinical recommendations and outcomes in adult patients with OHCA, using data from the All‐Japan Utstein Registry, a prospective, nationwide, population‐based registry of OHCA.METHODSIn this study, 73 874 adults from the All‐Japan Utstein Registry diagnosed with nonshockable OHCA that had been witnessed by bystanders or emergency medical service responders between 2011 and 2020 were included. The study outcomes were compared between 2012 and 2014 of the CoSTR 2010 era (2010 group) and 2017 and 2019 of the CoSTR 2015 era (2015 group).RESULTSThe adjusted odds ratio for the 30‐day neurologically intact survival in the 2015 bystander‐witnessed group compared with the 2010 group was 1.175 (95% CI, 1.014–1.362; P=0.032). Similar results were observed in the emergency medical service responder‐witnessed group.CONCLUSIONSThe cardiopulmonary resuscitation maneuver updates recommended by CoSTR 2015 for nonshockable OHCA were associated with higher survival rates without neurological complications compared with those recommended by CoSTR 2010 in Japan.REGISTRATIONURL: http://www.umin.ac.jp/ctr/. Unique identifier: 000009918.