Endovascular coiling may receive increased consideration in the elderly ( 70 years of age), in those presenting with poor-grade Connolly et al Management of Aneurysmal Subarachnoid Hemorrhage 1721 (World Federation of Neurological Surgeons classi- fication IV/V) aSAH, and in those with aneurysms of the basilar apex (Class IIb; Level of Evidence C). (New recommendation) 7. Stenting of a ruptured aneurysm is associated with increased morbidity and mortality, and should only be considered when less risky options have been excluded (Class III; Level of Evidence C). (New recommendation) Hospital Characteristics and Systems of Care In a US study of 31 476 nontraumatic cases of aSAH from 2003, definitive aneurysm repair was delivered in fewer than one third of cases. That said, the adjusted odds of definitive repair were significantly higher in urban teaching hospitals than in urban nonteaching hospitals (odds ratio, 1.62) or rural hospitals (odds ratio, 3.08).7 In another study from 1993 to 2003, teaching status and larger hospital size were associated with higher charges and longer stay but also with better outcomes (P 0.05) and lower mortality rates (P 0.05), especially in patients who underwent aneurysm clipping (P 0.01). Endovascular treatment, which was more often used in the elderly, was also associated with significantly higher mortality rates in smaller hospitals (P 0.001) and steadily increasing morbidity rates (45%). 