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side, or other medication to reduce greatly elevated blood pressure and then maintain systolic blood pressure at 150 mmHg or less; and pain-relieving medication for headache (this alone will often reduce the hypertension) The prevention of systemic venous thrombosis is critical, usually accomplished by the use of cyclically in ated whole-leg compression boots The use of anticonvulsants is controversial; many neurosurgeons administer them early, with a view of preventing a seizure-induced risk of rebleeding We have generally avoided them unless a seizure has occurred Calcium channel blockers are being used extensively to reduce the incidence of stroke from vasospasm Nimodipine 60 mg, administered orally every 4 h, is currently favored Although calcium channel blockers do not alter the incidence of angiographically demonstrated vasospasm, they have reduced the number of strokes in each of ve randomized studies, beginning with the one conducted by Allen and colleagues Several groups have been using angioplasty techniques to dilate vasospastic vessels and reporting symptomatic improvement, but there are as yet insuf cient controlled data to judge the merits and safety of this procedure The most notable advances have been in the techniques for the obliteration of aneurysms, particularly the operating microscope and endovascular approaches, and in the management of circulatory volume In the majority of patients intravascular volume is depleted in the days after subarachnoid hemorrhage This, in turn, greatly increases the chances of ischemic infarction from vasospasm, though it does not alter its incidence or severity In part, this volume contraction can be attributed to bed rest, but sodium loss, probably resulting from the release of atrial natriuretic factor (ANF), a potent oligopeptide stimulator of sodium loss in renal tubules, may also be a factor Hyponatremia develops in the rst week after hemorrhage, but it is unclear whether this also results from the natriuretic effects of ANF or is an effect of antidiuretic hormone, causing water retention The work of Diringer and coworkers suggests that both mechanisms are operative, but we would emphasize that it is the volume depletion, not hyponatremia per se, that is of the greatest clinical consequence Both the risk of rerupture of the aneurysm and some of the secondary problems that arise because of the massive amount of blood in the subarachnoid space can be obviated by early obliteration of the aneurysm Because of the changes in water balance and the risk of delayed stroke from vasospasm, there has been an emphasis on early volume expansion and sodium repletion by the intravenous infusion of crystalloids As Solomon and Fink have pointed out, this can be accomplished with relative safety and without fear of aneurysmal rupture if blood pressure is allowed to rise only minimally And, or course, uid replacement and a modest elevation of blood pressure become completely safe if the aneurysm has been surgically occluded Thus the current approach is to operate early, within 36 h if possible, on all patients in grades I and II and then to increase intravascular volume and maintain normal or above-normal blood pressures This eliminates the risk of rebleeding, with its high mortality, and helps prevent the second cause of morbidity, stroke from vasospasm The timing of surgery or endovascular treatment for grade III patients is still controversial, but if their medical condition allows, they too probably bene t from the same early and aggressive approach In grade IV patients, the outcome is generally dismal, no matter what course is taken, but we have usually counseled against early operation; some neurosurgeons disagree The insertion of ventricular drains into both frontal horns has occasionally raised a patient with severe hydrocephalus to a better grade and facilitated early operation In the.

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