Just as Darwin introduced the concept of evolution as occurring by quantum leaps, so the endovascular management of intracranial aneurysms represents medical quantum evolution. We are used to physicians moving jobs but not losing or changing jobs. Image-guided therapy is, in Business Language lingo, a "destructive" technology that is redistributing the care of patients with intracranial aneurysms amongst new tribes of physicians called "endovascular neurosurgeons" or "neurointerventional radiologists." Our job is to best inform the patient of their therapeutic options and ensure that they are equally safe in all hands. A discussion of these options follows.

Aneurysmal subarachnoid hemorrhage (aSAH) represents the most common nontraumatic etiology of subarachnoid hemorrhage (SAH). CT scan is 95% (1) sensitive in detecting SAH (2). In approximately 94% of patients with a spontaneous SAH, angiography will detect a causal lesion, principally, an aneurysm (3). In 6% of cases, no cause will be identified; these are considered angionegative SAH. Current management strategies include repeating cerebral angiography after 7 to 10 days, during which a number of patients will rebleed. One study found that, in 15% of patients with spontaneous SAH, the source of bleeding could not be determined despite repeat angiography; most of these patients will have a very typical perimesencephalic distribution of SAH (4). It has been suggested that magnetic resonance angiography (MRA), in conjunction with CT results, be performed in patients with SAH of unknown etiology before catheter angiography is repeated (3). Patients with angiographically negative SAH have a better course, with better neurologic status, fewer complications, and better outcomes, than patients with positive findings on angiogram; therefore, it has been suggested that repeat angiograms be performed only on patients with atypical blood distribution for angionegative SAH (5). Repeat angiography plays an important role in defining the site of an initially occult aneurysm, particularly if the initial angiogram was compromised by vasospasm or if one part of the vascular tree was not optimally visualized (6).

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