Background and Purpose- ISAT (International Subarachnoid Aneurysm Trial) demonstrated that 1 year after aneurysmal subarachnoid hemorrhage, coiling resulted in a significantly better clinical outcome than clipping. After 5 years, this difference did not reach statistical significance, but mortality was still higher in the clipping group. Here, we present additional analyses, reporting outcome after excluding pretreatment deaths. Methods- Outcome measures were death with or without dependency at 1 and 5 years after treatment, after exclusion of all pretreatment deaths. Treatment differences were assessed using relative risks (RRs). With sensitivity and exploratory analyses, the relation between treatment delay and outcome was analyzed. Results- After exclusion of pretreatment deaths, at 1-year follow-up coiling was favorable over clipping for death or dependency (RR, 0.77 [95% CI, 0.67-0.89]) but not for death alone (RR, 0.88 [95% CI, 0.66-1.19]). After 5 years, no significant differences were observed, neither for death or dependency (RR, 0.88 [95% CI, 0.77-1.02]) nor for death alone (RR, 0.82 [95% CI, 0.64-1.05]). Sensitivity analyses showed a similar picture. In good-grade patients, coiling remained favorable over clipping in the long-term. Time between randomization and treatment was significantly longer in the clipping arm (mean 1.7 versus 1.1 days; P<0.0001), during which 17 patients died because of rebleeding versus 6 pretreatment deaths in the endovascular arm (RR, 2.81 [95% CI, 1.11-7.11]). Conclusions- These additional analyses support the conclusion of ISAT that at 1-year follow-up after aneurysmal subarachnoid hemorrhage coiling has a better outcome than clipping. After 5 years, with pretreatment mortality excluded, the difference between coiling and clipping is not significant. The high number of pretreatment deaths in the clipping group highlights the importance of urgent aneurysm treatment to prevent early rebleeding.

中文翻译：

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国际蛛网膜下腔动脉瘤试验中治疗延迟对预后的影响。

背景与目的-ISAT（国际蛛网膜下腔动脉瘤试验）表明，在动脉瘤性蛛网膜下腔出血1年后，与截断相比，盘绕可显着改善临床效果。5年后，这种差异没有达到统计学显着性，但是修剪组的死亡率仍然更高。在这里，我们提出了其他分析，报告了排除治疗前死亡后的结果。方法-结果指标是在排除所有治疗前死亡后，在治疗后1年和5年有或没有依赖性的死亡。使用相对风险（RR）评估治疗差异。通过敏感性和探索性分析，分析了治疗延迟和结果之间的关系。结果-在排除治疗前死亡后，在1年的随访中，对于死因或依赖性（RR，0.77 [95％CI，0.67-0.89]），盘绕优于削减，但对于单独的死亡（RR，0.88 [95％CI，0.66-1.19]）不利。5年后，无论是死亡还是依存度（RR，0.88 [95％CI，0.77-1.02]）或单独死亡（RR，0.82 [95％CI，0.64-1.05]）都没有发现显着差异。敏感性分析显示出相似的图景。从长远来看，在高品位患者中，卷绕比剪裁仍然有利。钳夹组中随机分组到治疗之间的时间明显更长（分别为1.7天和1.1天； P <0.0001），在此期间有17例患者因再出血而死亡，而在血管内组中有6例预处理死亡（RR，2.81 [95％CI，1.11] -7.11]）。结论-这些额外的分析支持了ISAT的结论，即动脉瘤蛛网膜下腔出血盘绕术后1年随访的结果要好于截断。5年后，不考虑预处理死亡率，卷曲和削幅之间的差异并不显着。截肢组中大量的预处理死亡事件突显了紧急动脉瘤治疗对防止早期再出血的重要性。