To determine how clinical grade after subarachnoid hemorrhage impacts operative characteristics and the incidence of intra- and postoperative surgical complications, we retrospectively compared the surgical management of all good grade (n = 224) and poor grade (n = 131) patients who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The majority of good grade (74.2%) and poor grade (89.8%) patients underwent surgery < 3 days after subarachnoid hemorrhage. The results in this series demonstrate that severe cerebral swelling, often secondary to intracerebral hemorrhage, was significantly more frequent in poor grade patients. The incidence of complications, such as failure to occlude the aneurysm, major vessel occlusion, intraoperative aneurysm rupture, or surgical contusion, however, was similar in poor grade and good grade patients. We conclude, therefore, that except for severe cerebral swelling associated with intracerebral hemorrhage, the risk of surgical complications is similar in good and poor grade patients undergoing surgical repair of ruptured anterior circulation aneurysms.