Advanced age is associated with a less favorable outcome following aneurysmal SAH, in large part, because of associated medical conditions. Nevertheless, available data suggest that elderly patients often benefit from aggressive treatment and that a reasonable outcome at a reasonable cost can be expected in selected patients. Emerging technologies such as endovascular treatment of ruptured and unruptured aneurysms continue to improve treatment options in the elderly population. Physiologic rather than chronologic age together with the patient's clinical condition and personal and family considerations should form the basis of any recommended treatment approach in the elderly patient with a cerebral aneurysm.