Aneurysmal subarachnoid haemorrhage (SAH) is the second commonest neurosurgical emergency, affecting 2000 people in Australia and 6000 in Britain each year. Mortality averages 33% with half the survivors having significant neurological deficit. Much of this mortality and morbidity is preventable, and in specialist centres mortality may be reduced to less than 10% without increasing the number of neurologically-impaired survivors. Expectant low-volume management in general hospitals without neurosurgical, neuroradiological or neurological intensive care services exposes patients to preventable mortality from rebleeding, vasospasm and medical complications. Such management may be considered sub-optimal care. State of the art management includes early surgical or radiological obliteration of the aneurysm, vasospasm prophylaxis, and treatment of confirmed vasospasm with induced hypertension and chemical or balloon angioplasty. Evidence is accumulating that outcome for patients with traumatic SAH, who outnumber those with aneurysmal SAH, may be improved by a similar approach.