The ruptured aneurysm with an intracerebral haematoma is a commonly encountered neurosurgical emergency. The options for management of this situation have evolved with the changes in neurovascular surgery training and widespread use of endovascular techniques for aneurysm occlusion. This Element will discuss the differences between subarachnoid haemorrhage with or without an intracerebral haematoma including presentation, imaging and outcomes. The authors present their preferred surgical strategy including practical guidance on how to handle difficult situations such as the intra-operative rupture.