This is the longest reported follow-up of patients with ruptured intracranial aneurysms treated entirely medically with hypotension. Patients with ruptured brain aneurysms, untreated except for plain bedrest, are at a well-recognized risk of recurrent hemorrhage. Some surgically treated patients also remain at risk of recurrent hemorrhage in follow-up. This is a review of results in patients whose active but entirely medical (hypotensive) treatment was started in the first 10 years of a 40-year study. It suggests a way of reducing risks in both of the above 2 groups. 53 consecutive patients with proven ruptured brain aneurysm(s) were treated as early as possible with medical-hypotensive therapy alone by the author and followed, personally, until death or, if they survived, for at least 30 years each (or until lost to follow-up). The patients included many considered to have been poor operative risks with some having been designated inoperable by the referring neurosurgeons. As part of the long-term follow-up, magnetic resonance angiography (MRA) has been begun. Long-term follow-up was defined as the time beginning after 9 weeks from (admission) hemorrhage. 9 patients had died during the earlier stages of hemorrhage (and treatment) i.e., before the 9 weeks period had elapsed; their data was presented previously. This yielded 44 patients for long-term follow-up. Only 2 patients (both had multiple aneurysms) on this regimen have died of either proven hemorrhage (1 patient) or presumed hemorrhage (1 patient). Most patients survived and maintained an excellent condition. Medical-hypotensive therapy of ruptured intracranial aneurysms has produced much better long-term results than expected. This is significant for (1) patients requiring medical treatment alone and (2) surgically treated patients who may benefit from additional long-term protection.