BACKGROUNDCraniotomy for hematoma evacuation and aneurysm clipping is the treatment modality of choice for ruptured middle cerebral artery (MCA) aneurysms with intracranial hematomas. Recent literature suggests that endovascular coil embolization followed by hematoma evacuation can be an acceptable alternative.OBJECTIVETo determine neurological outcomes in patients with ruptured MCA aneurysms and intraparenchymal or sylvian fissure hematomas.METHODSThe records of 49 patients with ruptured MCA aneurysms with large intracranial hematomas treated with hematoma evacuation and aneurysm clipping between January 2000 and December 2013 were retrospectively reviewed.RESULTSWithin this cohort, 35 patients (71.4%) were Hunt and Hess grade IV or V on presentation. The mean hematoma volume was 100.4 ± 77.2 mL. Craniectomy was performed in 40 patients (81.6%). Angiographic vasospasm developed in 15 patients (30.6%). The in-hospital mortality rate was 28.6% (14 patients). At a mean of 25.3 ± 34.0 months follow-up, a good outcome (modified Rankin Scale [mRS] score 0-3) was observed in 18 patients (36.7%). Significant factors associated with poor outcome or death (mRS scores of 4-6) included increasing age (P < .01), increasing Hunt and Hess grade (P = .03), increasing modified Fisher grade (P = .01), presence of intraventricular hemorrhage (P < .01), decreasing percentage of hematoma evacuation (P < .05), need for craniectomy (P CONCLUSIONMCA aneurysm rupture with concomitant large intraparenchymal or sylvian fissure hematoma formation carries a grave prognosis. Simultaneous hematoma evacuation and aneurysm clipping with or without craniectomy can be an effective treatment modality.