The paper by Lafuente and Maurice-Williams on p 1680–1684 describes a well documented, consecutive, personal series of neurosurgically treated patients with aneurysmal sub-arachnoid haemorrhage, and it puts the finger on a sore spot.

Since the early 1960s, not more than two randomised controlled trials of surgical interventions in aneurysmal subarachnoid haemorrhage have been published. As a result, we are still not sure whether patients should be operated early, whether it would be safe enough to operate in the 4–10 day period when risks of ischaemia are high, and whether surgery in patients with a lowered level of consciousness should be postponed, or not. It was therefore virtually impossible to make a surgical management strategy that fits the risk profile of the individual patient and …