In this case series study, the surgical outcomes of 29 patients with intracerebral hematomas resulting from the rupture of middle cerebral artery aneurysms that were operated on within the first 12 hours after rupture were retrospectively analyzed. Preoperative cerebral angiography could be obtained in 12 (41.3%) of our patients. Outcome was assessed according to the Glasgow Outcome Scale at 6 months after surgery. Overall mortality was 48%. Of 12 patients in good preoperative condition, 6 (50%) had a favorable outcome (Glasgow Outcome Scale, 4 to 5), whereas of the 17 patients in poor preoperative condition only 1 (5.8%) had a favorable outcome (P = 0.042). Our results suggest that despite early surgical treatment of patients with ruptured middle cerebral artery aneurysms associated with massive intracerebral hematoma, mortality continues to be high in patients with poor preoperative grades.