Assessing Outcome Measurements and Impact of Simulation in Neurocritical Care Training: A Systematic Review.

ABSTRACT: AIM: The use of simulation training in neurocritical care is increasing. Yet, the pooled impact on patient and trainee outcomes remains unclear. This systematic review aims to determine the outcome measurements used after simulation training in neurocritical care and to synthesize the current evidence about the impact of simulation training on these outcomes. METHODS: A 3-step search was conducted in CINAHL, Cochrane, MEDLINE, PsychINFO, and Scopus. The inclusion criteria were composed of studies exploring simulation training in neurocritical care, published in English between 2000 and 2023. Two reviewers independently conducted screening, critical appraisal, and data extraction, using standardized Joanna Briggs Institute tools. Meta-analysis was precluded because of clinical, methodological, and statistical heterogeneity. RESULTS: Nine relevant studies were found: 1 quality improvement project and 8 quasi-experimental studies. The overall quality of the relevant studies was moderate to high (61.1%-77.8%). Three types of outcome measurements for simulation in neurocritical care were identified: knowledge and clinical performance; confidence and comfort; and teamwork, communication, and leadership skills. Simulation training was associated with a significant improvement in knowledge and clinical performance, and confidence and comfort, but not in communication and leadership skills. CONCLUSION: Significant improvement in trainees' outcomes was observed. The current literature includes significant heterogeneity in the methods of evaluating simulation outcomes, although no patient outcomes were observed. Investigating the effect of simulation in neurocritical care training on patient outcomes in future studies is warranted.

Delirium incidence, predictors and outcomes in the intensive care unit: A prospective cohort study.

AIM: The aim of this study was to investigate the incidence, predictors, and outcomes of delirium in intensive care units. BACKGROUND: Delirium is a common complication in intensive care units. In developing countries, it can be misdiagnosed or unrecognised. DESIGN: Prospective cohort study reported according to the strengthening the reporting of observational studies in epidemiology criteria. METHODS: We included patients who were conscious, >18 years old, and admitted to the intensive care units for at least 8 h between December 2019 and February 2020. Patients with a Richmond score of -4 or -5, mental disability, receptive aphasia and/or visual or auditory impairment were excluded from the study. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU), whereas the functional outcome was assessed by the Katz Activity of Daily Living Index. RESULTS: This study included 111 patients with a delirium incidence of 31.5%. The severity of illness was the only significant predictor of delirium. Patients with delirium had longer intensive care unit and in-hospital stays in contrast to those without delirium. Delirium was associated with in-hospital and 4-month mortality but not the activities of daily living. CONCLUSIONS: Delirium is associated with increased length of stay and mortality. Further investigation to determine whether delirium management can improve outcomes is warranted.

Nurse-guided incentive spirometry use and postoperative pulmonary complications among cardiac surgery patients: A randomized controlled trial.

AIMS: To assess the effect of nurse-guided use of incentive spirometer on postoperative oxygenation and pulmonary complications after coronary artery bypass graft surgery. BACKGROUND: Deep breathing exercises have been shown to improve postoperative lung expansion and reduce pulmonary complications. An incentive spirometer is a deep breathing exercises device that imitates continuous sigh-like maximal inspiration. DESIGN: Randomized control trial, two groups nonblinded parallel design. METHODS: A total of n = 89 eligible patients were randomized to either control or intervention group. Patients in the intervention group received bihourly nurse-guided incentive spirometry for 48-h postextubation. The endpoints were: the number and duration of hypoxic events during the first 24-hr postsurgery, pneumonia and pulmonary function parameters. Data were collected May to September 2019. RESULTS: Patients in the intervention group had a significantly lower mean number of hypoxic events with shorter duration and shorter length of stay in the hospital and the ICU. Patients in the intervention group also had greater postoperative forced expiratory volume in 1 second. CONCLUSION: Nurse-guided use of the incentive spirometer reduces the risk of pulmonary complications and hospital length of stay after cardiac surgery.

Neurocardiac Injury Assessed by Strain Imaging Is Associated With In-Hospital Mortality in Patients With Subarachnoid Hemorrhage.

OBJECTIVES: This study sought to test the hypothesis that speckle tracking strain echocardiography can quantify neurocardiac injuries in patients with aneurysmal subarachnoid hemorrhage (SAH), which is associated with worse clinical outcome. BACKGROUND: SAH may be a life-threatening disease associated with variable degrees of neurocardiac injury. Strain imaging has the potential to detect subtle myocardial dysfunction which is additive to conventional measurements. METHODS: A total of 255 consecutive patients were prospectively enrolled with acute SAH, who were admitted to the intensive care unit with echocardiography studies within 72 h. Left ventricular (LV) and right ventricular (RV) strains were acquired from standard apical views. Abnormal LV global longitudinal strain (GLS) and RV free-wall strain were pre-defined as <17% and <23% (absolute values), respectively. RESULTS: Performing LV GLS was feasible in 221 patients (89%) 53 ± 10 years of age, 71% female, after excluding those with previous cardiac disease. Abnormal LV GLS findings were observed in 53 patients (24%) and were associated with worse clinical severity, including a Hunt-Hess grade >3 (34% vs. 15%; p = 0.005) and biomarker evidence of neurocardiac injury and higher troponin values (1.50 [interquartile range (IQR): 0.01 to 3.87] vs. 0.01 [IQR: 0.01 to 0.22] ng/ml; p < 0.001). A reverse Takotsubo pattern of segmental strain was observed in 49% of patients (apical sparing and reduced basal strain). Importantly, LV GLS was more strongly associated with in-hospital mortality than left ventricular ejection fraction (LVEF), even after adjusting for clinical severity (odds ratio [OR]: 3.11; 95% confidence interval [CI]: 1.12 to 8.63; p = 0.029). RV strain was measured in 159 subjects (72%); abnormal RV strain was added to LV GLS for predicting in-hospital mortality (p = 0.007). CONCLUSIONS: Neurocardiac injury can be detected by LV GLS and RV strain in patients with acute SAH. LV GLS was significantly associated with in-hospital mortality. RV strain, when available, added prognostic value to LV GLS. Abnormal myocardial strain is a marker for increased risk of in-hospital mortality in SAH and has clinical prognostic utility.

Cardiovascular Disease Risk Predicts Health Perception in Prison Inmates.

We hypothesized that risk factors for cardiovascular disease (CVD) would be associated with worse health perceptions in prison inmates. This study included 362 inmates recruited from four medium security prisons in Kentucky. Framingham Risk Score was used to estimate the risk of developing CVD within the next 10 years. A single item on self-rated health from the Medical Outcomes Survey-Short Form 36 was used to measure health perception. Multinomial logistic regression showed that for every 1-unit increase in Framingham Risk Score, inmates were 23% more likely to have rated their health as fair/poor and 11% more likely to rate their health as good rather than very good/excellent. These findings demonstrate that worse health perceptions may serve as a starting point for discussing cardiovascular risk factors and prevention with inmates.

Vasopressor Infusion After Subarachnoid Hemorrhage Does Not Increase Regional Cerebral Tissue Oxygenation.

INTRODUCTION: Vasopressors are commonly used after aneurysmal subarachnoid hemorrhage (aSAH) to sustain cerebral pressure gradients. Yet, the relationship between vasopressors and the degree of cerebral microcirculatory support achieved remains unclear. This study aimed to explore the changes in cerebral and peripheral regional tissue oxygen saturation (rSO2) as well as blood pressure (BP) before and after vasopressor infusion in patients with aSAH. METHODS: Continuous noninvasive cerebral and peripheral rSO2 was obtained using near-infrared spectroscopy for up to 14 days after aSAH. Within-subject differences in rSO2 before and after the commencement of vasopressor infusion were analyzed controlling for Hunt and Hess grade and vasospasm. RESULTS: Of 45 patients with continuous rSO2 monitoring, 19 (42%) received vasopressor infusion (all 19 on norepinephrine, plus epinephrine in 2 patients, phenylephrine in 4 patients, and vasopressin in 2 patients). In these 19 patients, their vasopressor infusion times were associated with higher BP (systolic [b = 15.1], diastolic [b = 7.3], and mean [b = 10.1]; P = .001) but lower cerebral rSO2 (left cerebral rSO2 decreased by 4.4% [b = -4.4, P < .0001]; right cerebral rSO2 decreased by 5.5% [b = -5.5, P = .0002]). CONCLUSIONS: Despite elevation in systemic BP during vasopressor infusion times, cerebral rSO2 was concurrently diminished. These findings warrant further investigation for the effect of induced hypertension on cerebral microcirculation.

Analyzing Cyber-Physical Threats on Robotic Platforms.

Robots are increasingly involved in our daily lives. Fundamental to robots are the communication link (or stream) and the applications that connect the robots to their clients or users. Such communication link and applications are usually supported through client/server network connection. This networking system is amenable of being attacked and vulnerable to the security threats. Ensuring security and privacy for robotic platforms is thus critical, as failures and attacks could have devastating consequences. In this paper, we examine several cyber-physical security threats that are unique to the robotic platforms; specifically the communication link and the applications. Threats target integrity, availability and confidential security requirements of the robotic platforms, which use MobileEyes/arnlServer client/server applications. A robot attack tool (RAT) was developed to perform specific security attacks. An impact-oriented approach was adopted to analyze the assessment results of the attacks. Tests and experiments of attacks were conducted in simulation environment and physically on the robot. The simulation environment was based on MobileSim; a software tool for simulating, debugging and experimenting on MobileRobots/ActivMedia platforms and their environments. The robot platform PeopleBotTM was used for physical experiments. The analysis and testing results show that certain attacks were successful at breaching the robot security. Integrity attacks modified commands and manipulated the robot behavior. Availability attacks were able to cause Denial-of-Service (DoS) and the robot was not responsive to MobileEyes commands. Integrity and availability attacks caused sensitive information on the robot to be hijacked. To mitigate security threats, we provide possible mitigation techniques and suggestions to raise awareness of threats on the robotic platforms, especially when the robots are involved in critical missions or applications.

Stress, cognitive appraisal, coping, and event free survival in patients with heart failure.

OBJECTIVES: To describe self-reported stress level, cognitive appraisal and coping among patients with heart failure (HF), and to examine the association of cognitive appraisal and coping strategies with event-free survival. METHODS: This was a prospective, longitudinal, descriptive study of patients with chronic HF. Assessment of stress, cognitive appraisal, and coping was performed using Perceived Stress Scale, Cognitive Appraisal Health Scale, and Brief COPE scale, respectively. The event-free survival was defined as cardiac rehospitalization and all-cause death. RESULTS: A total of 88 HF patients (mean age 58 ± 13 years and 53.4% male) participated. Linear and cox regression showed that harm/loss cognitive appraisal was associated with avoidant emotional coping (ß = -0.28; 95% CI: -0.21 - 0.02; p = 0.02) and event free survival (HR = 0.53; 95% CI: 0.28 - 1.02; p = 0.05). CONCLUSIONS: The cognitive appraisal of the stressors related to HF may lead to negative coping strategies that are associated with worse event-free survival.

The Association Between Depressive Symptoms and N-Terminal Pro-B-Type Natriuretic Peptide With Functional Status in Patients With Heart Failure.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) and depressive symptoms are each associated with functional status in patients with heart failure (HF), but their association together with functional status has not been examined. OBJECTIVE: The aim of this study was to determine whether functional status scores differ as a function of depressive symptoms and NT-proBNP levels considered together. METHODS: We studied 284 patients with HF who were divided into 4 groups based on the median split of NT-proBNP levels and cut point for depressive symptoms (Beck Depression Inventory ≥ 14): (1) low NT-proBNP of 562.5 pg/mL or less without depressive symptoms, (2) low NT-proBNP of 562.5 pg/mL or less with depressive symptoms, (3) high NT-proBNP of greater than 562.5 pg/mL without depressive symptoms, and (4) high NT-proBNP of greater than 562.5 pg/mL with depressive symptoms. The Duke Activity Status Index was used to assess functional status. RESULTS: Nonlinear regression demonstrated that patients without depressive symptoms were more than twice as likely to have higher (better) functional status scores than patients with depressive symptoms regardless of NT-proBNP levels after controlling for age, gender, prescribed antidepressants, and body mass index. Functional status levels of patients with low NT-proBNP did not differ from those with high NT-proBNP in the presence of depressive symptoms. CONCLUSION: When examined together, depressive symptoms rather than NT-proBNP levels predicted functional status. CLINICAL IMPLICATIONS: Adequate treatment of depressive symptoms may lead to better functional status regardless of HF severity.

Clinical Presentation to the Emergency Department Predicts Subarachnoid Hemorrhage-Associated Myocardial Injury.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) is frequently seen in emergency departments. Secondary injury, such as subarachnoid hemorrhage-associated myocardial injury (SAHMI), affects one third of survivors and contributes to poor outcomes. SAHMI is not attributed to ischemia from myocardial disease but can result in hypotension and arrhythmias. It is important that emergency nurses recognize which clinical presentation characteristics are predictive of SAHMI to initiate proper interventions. The aim of this study was to determine whether patients who present to the emergency department with clinical aSAH are likely to develop SAHMI, as defined by troponin I ≥0.3 ng/mL. METHODS: This was a prospective descriptive study. SAHMI was defined as troponin I ≥0.3 ng/mL. Predictors included demographics and clinical characteristics, severity of injury, admission 12-lead electrogardiogram (ECG), initial emergency department vital signs, and pre-hospital symptoms at time of aneurysm rupture. RESULTS: Of 449 patients, 126 (28%) had SAHMI. Patients with SAHMI were more likely to report seizures and unresponsiveness with significantly lower Glasgow coma score and higher proportion of Hunt and Hess grades 3 to 5 and Fisher grades III and IV (all P < .05). Patients with SAHMI had higher atrial and ventricular rates and longer QTc intervals on initial ECG (P < .05). On multivariable logistic regression, poor Hunt and Hess grade, report of prehospital unresponsiveness, lower admission Glasgow coma score, and longer QTc interval were significantly and independently predictive of SAHMI (P < .05). DISCUSSION: Components of the clinical presentation of subarachnoid hemorrhage to the emergency department predict SAHMI. Identifying patients with SAHMI in the emergency department can be helpful in determining surveillance and care needs and informing transfer unit care. Contribution to Emergency Nursing Practice.

Extrinsic Calibration of Camera and 2D Laser Sensors without Overlap.

Extrinsic calibration of a camera and a 2D laser range finder (lidar) sensors is crucial in sensor data fusion applications; for example SLAM algorithms used in mobile robot platforms. The fundamental challenge of extrinsic calibration is when the camera-lidar sensors do not overlap or share the same field of view. In this paper we propose a novel and flexible approach for the extrinsic calibration of a camera-lidar system without overlap, which can be used for robotic platform self-calibration. The approach is based on the robot-world hand-eye calibration (RWHE) problem; proven to have efficient and accurate solutions. First, the system was mapped to the RWHE calibration problem modeled as the linear relationship AX = ZB , where X and Z are unknown calibration matrices. Then, we computed the transformation matrix B , which was the main challenge in the above mapping. The computation is based on reasonable assumptions about geometric structure in the calibration environment. The reliability and accuracy of the proposed approach is compared to a state-of-the-art method in extrinsic 2D lidar to camera calibration. Experimental results from real datasets indicate that the proposed approach provides better results with an L2 norm translational and rotational deviations of 314 mm and 0 . 12 ∘ respectively.

The Relationships Between BNP and Neurocardiac Injury Severity, Noninvasive Cardiac Output, and Outcomes After Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: Neurocardiac injury, a type of myocardial dysfunction associated with neurological insult to the brain, occurs in 31-48% of aneurysmal subarachnoid hemorrhage (aSAH) patients. Cardiac troponin I (cTnI) is commonly used to diagnose neurocardiac injury. Brain natriuretic peptide (BNP), another cardiac marker, is more often used to evaluate degree of heart failure. The purpose of this study was to examine the relationships between BNP and (a) neurocardiac injury severity according to cTnI, (b) noninvasive continuous cardiac output (NCCO), and (c) outcomes in aSAH patients. METHOD: This descriptive longitudinal study enrolled 30 adult aSAH patients. Data collected included BNP and cTnI levels and NCCO parameters for 14 days and outcomes (modified Rankin Scale [mRS] and mortality) at discharge and 3 months. Generalized estimating equations were used to evaluate associations between BNP and cTnI, NCCO, and outcomes. RESULTS: BNP was significantly associated with cTnI. For every 1 unit increase in log BNP, cTnI increased by 0.05 ng/ml ( p = .001). Among NCCO parameters, BNP was significantly associated with thoracic fluid content ( p = .0003). On multivariable analyses, significant associations were found between BNP and poor mRS. For every 1 unit increase in log BNP, patients were 3.16 times more likely to have a poor mRS at discharge ( p = .021) and 5.40 times more likely at 3 months ( p < .0001). CONCLUSION: There were significant relationships between BNP and cTnI and poor outcomes after aSAH. BNP may have utility as a marker of neurocardiac injury and outcomes after aSAH.

Cerebral Perfusion Pressure and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Whether delayed cerebral ischemia (DCI) mediates the relationship between Hunt and Hess grade and outcomes after aneurysmal subarachnoid hemorrhage remains unknown. OBJECTIVES: To investigate the relationship between cerebral perfusion pressure, DCI, Hunt and Hess grade, and outcomes after aneurysmal subarachnoid hemorrhage. METHODS: DCI was defined as neurological deterioration due to impaired cerebral blood flow. Relationships between minimum cerebral perfusion pressure and onset and occurrence of DCI were tested by using logistic regression and the accelerated failure time model. The mediation effect of DCI on relationships between Hunt and Hess grade and outcomes was tested by using the bootstrap confidence interval. Outcomes at 3 and 12 months included mortality and neuropsychological, functional, and physical outcomes. RESULTS: DCI occurred in 211 patients (42%). About one-third of the patients had poor functional outcome at 3 (32%) and 12 (30%) months. Impaired neuropsychological outcome was observed in 33% of patients at 3 months and 17% at 12 months. For every increase of 10 mm Hg in cerebral perfusion pressure, odds for DCI increased by 2.78 (95% CI, 2.00-3.87). High perfusion pressure was associated with earlier onset of DCI (P < .001). CONCLUSIONS: DCI does not mediate the relationship of Hunt and Hess grade to functional outcome or death. The relationship between cerebral perfusion pressure and DCI was most likely due to induced hypertension and hypervolemia. Clinical guidelines may need to include limits for induced hypertension.

Temporal Profiles of Cerebral Perfusion Pressure After Subarachnoid Hemorrhage.

INTRODUCTION: Insufficient cerebral perfusion pressure (CPP) after aneurysmal subarachnoid hemorrhage can impair cerebral blood flow. We examined the temporal profiles of CPP change and tested whether these profiles were associated with delayed cerebral ischemia (DCI). METHOD: CPP values were retrospectively reviewed for 238 subjects. Intracranial pressure and mean arterial pressure values were obtained every 2 hours for 14 days. Induced hypertension was utilized to prevent vasospasm. The linear and quadratic CPP changes over time were tested using growth curve analysis. Multivariable logistic regression was utilized to examine the association between DCI and percentages of CPP values of >110, >100, <70, and <60 mm Hg. DCI was defined as neurological deterioration because of impaired cerebral blood flow. RESULTS: Between-subject differences accounted for 39% of variation in CPP values. There was a significant linear increase in CPP values over time (ß = 0.06, SE = 0.006, p < .001). The covariance (-0.52, SE = 0.09, p < .001) between initial CPP and linear parameter was negative, indicating that subjects with high CPP on admission had a slower rate of increase whereas those with low CPP had a faster rate of increase. For every 10% increase in the proportion of CPP of >100 or >110 mm Hg, the odds of DCI increased by 1.21 and 1.43, respectively (p < .05). CONCLUSIONS: The longer the time patients spent with high CPP, the greater the odds for DCI. When used prophylactically, induced hypertension contributes to higher CPP values. On the basis of the CPP trends and correlations observed, induced hypertension may not confer expected benefits in patients with aneurysmal subarachnoid hemorrhage.

Transcranial regional cerebral oxygen desaturation predicts delayed cerebral ischaemia and poor outcomes after subarachnoid haemorrhage: a correlational study.

OBJECTIVES: To examine the relationship between regional cerebral oxygen saturation (rSO2), delayed cerebral ischaemia (DCI), and outcomes after aneurysmal subarachnoid haemorrhage (aSAH). RESEARCH METHODOLOGY: Subjects (n = 163) with aSAH, age 21-75 years, and Fisher grade >1 were included in the study. Continuous rSO2 monitoring was performed for 5-10 days after injury using near-infrared spectroscopy with sensors over the frontal/temporal cortex. rSO2<50 indicated desaturation. DCI was defined as neurological deterioration due to impaired cerebral blood flow. Three- and 12-month functional outcomes were assessed by the modified Rankin scale (MRS) as good (0-3) and poor (4-6). RESULTS: DCI occurred in 57% of patients; of these 66% had rSO2<50. Overall, 56% had rSO2<50 on either side, 21% and 16% had poor MRS at 3 and 12 months. Subjects with rSO2 <50 were 3.25 times more likely to have DCI compared to those with rSO2 >50 (OR 3.25, 95%CI 1.58-6.69), positive predictive value (PPV) = 70%. Subjects with rSO2 <50 were 2.7 times more likely to have poor 3-month MRS compared to those with rSO2 >50 (OR 2.7, 95%CI 1.1-7.2), PPV = 70%. CONCLUSIONS: These results suggest that NIRS has the potential for detecting DCI after aSAH. This potential needs to be further explored in a larger prospective study.

Characteristics of patients with cardiorespiratory instability in a step-down unit.

BACKGROUND: Patients in step-down units are at higher risk for developing cardiorespiratory instability than are patients in general care areas. A triage tool is needed to identify at-risk patients who therefore require increased surveillance. OBJECTIVES: To determine demographic (age, race, sex) and clinical (Charlson Comorbidity Index at admission, admitting diagnosis, care area of origin, admission service) differences between patients in step-down units who did and did not experience cardiorespiratory instability. METHODS: In a prospective longitudinal pilot study, 326 surgical-trauma patients had continuous monitoring of heart rate, respirations, and oxygen saturation and intermittent noninvasive measurement of blood pressure. Cardiorespiratory instability was defined as heart rate less than 40/min or greater than 140/min, respirations less than 8/min or greater than 36/min, oxygen saturation less than 85%, or blood pressure less than 80 or greater than 200 mm Hg systolic or greater than 110 mm Hg diastolic. Patients' status was classified as unstable if their values crossed these thresholds even once during their stay. RESULTS: Cardiorespiratory instability occurred in 34% of patients. The Charlson Comorbidity Index was the only variable associated with instability conditions. Compared with patients with no comorbid conditions (50%), more patients with at least 1 comorbid condition (66%) experienced instability (P = .006). Each 1-unit increase in the Charlson Index increased the odds for cardiorespiratory instability by 1.17 (P = .03). CONCLUSION: Although the relationship between Charlson Comorbidity Index and cardiorespiratory instability was weak, adding it to current surveillance systems might improve detection of instability.

Predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a cardiac focus.

BACKGROUND: Myocardial injury after aneurysmal subarachnoid hemorrhage (aSAH) is associated with poor outcomes. Delayed cerebral ischemia (DCI) is also a complication of aSAH. We sought to determine whether (1) DCI could be predicted by demographics, aSAH severity/aneurysm location, or aSAH-associated myocardial injury (SAHMI), and (2) DCI is associated with increased mortality after aSAH. METHODS: Prospective longitudinal study of 149 aSAH subjects with definitive DCI evaluation, age 18-75 years, Hunt and Hess (HH) ≥ 3, and/or Fisher ≥ 2, and admitted to the Neurovascular ICU. DCI was defined by the presence of neurological deterioration accompanied by evidence of abnormal cerebral blood flow. RESULTS: Subjects were 48% DCI(+) and 52% DCI(-). DCI(+) subjects had more severe aSAH [HH (P = 0.002), Fisher (P = 0.004), admission Glasgow Coma Scale (P = 0.018)]. More DCI(+) subjects had pulmonary congestion than DCI(-) subjects (63 vs. 39%, P = 0.003). On echocardiogram, cardiac output (CO, liters per minute [LPM]) was significantly higher in DCI(+) than in DCI(-) subjects (6 ± 2 vs. 5 ± 1 LPM; P = 0.015). Multivariate analysis identified CO and Fisher grade as independent predictors of DCI (P = 0.02, 0.019). For each 1 LPM increase in CO, the odds of DCI increased by 1.5 (95% CI: 1.1-2.1). Fisher grade 4 increased the odds of DCI by 6.5 compared to Fisher grade 2 (95% CI: 1.6-25.8). After controlling for Fisher grade, CO remained an independent predictor of DCI (P = 0.02). Three-month mortality rate was not significantly different between DCI groups, P = 0.786. CONCLUSION: Elevated CO and Fisher grade are predictors of DCI after aSAH. However, prevention of DCI may not decrease mortality.

Cholangitis after coil embolization of an iatrogenic hepatic artery pseudoaneurysm: an unusual case report.

Pseudoaneurysm involving the hepatic arterial system is a recognized complication of biliary surgery. The standard nonsurgical treatment is coil embolization. We present a case of a patient who underwent coil embolization of a pseudoaneurysm and subsequently presented with ascending cholangitis due to migration of coils into the common bile duct.