In this retrospective study, the authors analyzed surgical outcomes in patients who suffered an intracerebral hemorrhage (ICH) as a result of a ruptured middle cerebral artery aneurysm. They studied 47 patients who underwent early aneurysm surgery and hematoma evacuation within 24 hours after onset of ICH. The types of ICH were classified into three groups according to their appearance on computerized tomography scanning: 1) temporal ICH; 2) intrasylvian hematoma; and 3) ICH with diffuse subarachnoid hemorrhage (SAH). Overall, 25 patients (53%) achieved a favorable outcome and 18 (38%) died. Factors that could be used to predict a favorable outcome included age less than 60 years, temporal ICH, World Federation of Neurological Surgeons Grade II or III, absence of a surgical complication, and a hematoma volume less than 25 ml. In the patients with temporal ICH, eight of nine patients achieved a good recovery and no patient developed a surgical complication or delayed ischemic deficit. The significant prognostic factor in patients with an intrasylvian hematoma was surgery within 6 hours after onset of symptoms. In patients with temporal ICH or intrasylvian hematoma, the results of the initial neurological examination did not accurately predict outcome. On the other hand, in patients with ICH and diffuse SAH, those patients who developed an ICH with a volume greater than 25 ml had a poor prognosis. These results indicate that aggressive surgical treatment should be performed in patients with a temporal ICH or an intrasylvian hematoma, regardless of the neurological findings on admission; in patients with ICH and diffuse SAH, a careful review of surgical indications is required.