Out of a total of 196 patients admitted with aneurysmal subarachnoid haemorrhage (SAH) to the neurological department in Mainz over a 42 month period, 48 patients (24.5%) were considered as grade IV or V on admission. Aneurysm surgery within 48 hours after SAH was performed in 56.3% of these patients, 2% were operated between day 3 and 7 and 16.6% were operated after day 7. 25% did not undergo operation because of severe neurological deficit and brain damage. The overall outcome according to the Glasgow outcome scale in the surgically treated group was full recovery in 11.1%, moderate disability in 16.7%, severe disability in 47.2%, vegetative state in 2.8% and death in 22.2%. All patients in the not operated group died. Good and moderate outcome was mainly seen in patients grade IV, which justify an aggressive strategy. Severe disability was mainly attributed to primary brain damage, while vasospasm played a minor role. Improvement may only be achieved by early referral of SAH patients to neurosurgical centres.