A neuroradiologic approach to the patient with a diagnosis of subarachnoid hemorrhage.

If early CT confirms the presence of subarachnoid hemorrhage, no intratemporal clot is present, and the patient is neurologically normal, surgery is planned in approximately eight to ten days. The first angiogram is performed just before surgery. If that angiogram shows severe vasospasm, surgery is deferred for approximately five to seven days. If the initial angiogram clearly shows the anatomy of the aneurysm and completely visualizes the intracranial circulation, it does not need to be repeated. If the initial angiogram is incomplete, then all vessels are studied prior to surgery. In cases of middle cerebral artery aneurysm with temporal clot, an angiogram is obtained early. In the future, early complete angiography followed by surgery may be possible in those patients with little blood on the initial CT scan. Those patients are not considered to be in jeopardy of developing severe vasospasm.