The role of antifibrinolytic drugs in the management of patients with aneurysmal subarachnoid hemorrhage continues to remain uncertain. Recent controlled studies suggest that although these agents may alter the course of the illness, they confer no benefit in terms of overall outcome. Confronted with these data, clinicians in North America have radically altered their management of patients with ruptured aneurysms in the last decade. In the Timing of Surgery Study (1980-1983), 54% of patients were treated with antifibrinolytic drugs and only 32% underwent surgical clipping of the aneurysm on days 0-3 from the subarachnoid hemorrhage. In contrast, only 13% of the patients in the Randomized Trial of Nicardipine in Subarachnoid Hemorrhage (1987-1989) received antifibrinolytics, whereas 53% had early surgery (unpublished observations). Further study will be required to determine if this strategy has resulted in an improvement in overall outcome. Some observers have suggested that as effective therapy for symptomatic vasospasm evolves (e.g., with hypertensive or hypervolemic therapy or calcium antagonists), the adverse effects of antifibrinolytic drugs on brain ischemia may be ameliorated. This idea must be confirmed by further evaluation of the combined use of these treatments. In the interim, antifibrinolytic drugs, if used at all, should be used with caution, and their use should be restricted to those patients judged not to be candidates for early surgery. If therapy cannot be started before day 7 after subarachnoid hemorrhage, it should not be started at all, as the reduced rate of rebleeding after the first 7 days does not justify the increased risk of brain ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)