Aneurysm surgery began in Lübeck only in 1986 when the department was completely reorganized. Early operation in the good grade patients (I-III, according to Hunt and Hess) was performed. In every case we also discussed the feasibility of operating on the poor grade patients (Hunt and Hess IV and V). During a five-year period (1986-1991) a total of 277 SAH patients were admitted to the department. 109 (39%) patients arrived in a poor grade (Hunt and Hess IV or V), 12 of these patients died within hours of admission. 25 patients, who presented with a large intracerebral and/or subdural haematoma, were urgently operated upon by haematoma evacuation and aneurysm clipping. An external ventricular drainage was performed on 72 patients. Of the ventriculostomy group 33 patients improved and 27 were operated upon. In 17 of the 39 patients without improvement after CSF-drainage we decided to operate. Overall 69 patients were surgically treated (craniotomy, aneurysm clipping) and 40 were not. The mortality rate in the surgical cases was 16 (23%) compared with 30 (75%) without operation. It is concluded that poor grade aneurysm patients can achieve a better outcome with active treatment based on immediate ventriculostomy and optimal haemodynamic parameters after haematoma evacuation and early occlusion of the aneurysm.