Subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm represents a major health issue. Although most people who experience an aneurysmal SAH survive to be admitted to a hospital, less than one third of these patients ever return to their premorbid status. Clearly, morbidity of this magnitude demands reevaluation of the clinical approach to this problem. This article reviews the natural history of aneurysmal SAH, and examines the current therapeutic strategies that have been suggested to improve the outcome. Careful evaluation of the existing data suggests that early aneurysm surgery and aggressive postoperative volume expansion therapy constitute the best presently available approach to patients with ruptured intracranial aneurysms.