Introduction: Patients presenting with high grade (HG) subarachnoid hemorrhage (SAH) from aneurysmal rupture may have persisting neurologic deficits which may lead to questioning the decision of treating aggressively. The objective of this study aims at analyzing outcome and long-term quality of life (QOL) of patients with HG SAH treated surgically. Methods: Retrospective study of patients with Hunt Hess (HH) grade IV or V SAH treated surgically at our institution. Long-term outcome was evaluated based on the modified Rankin Scale (mRS) at 3 years. Survivors were evaluated for QOL using various scales. Results: 63 patients (mean age of 52 year-old) were included. Intraparenchymal hemorrhage (IPH) was found in 85% of cases. 19 patients died. Predictive factors of poor prognosis and mortality were initial cerebral ischemia (p=0.003) and IPH (p=0.007). Favourable outcome (mRS 0-3) was found in 41% of patients. QOL questionnaires revealed that 80 % of responders showed more than 50% recovery. Mild or absent depression was observed in 78% of patients. Conclusion: In this surgical series, performed in an endovascular era, nearly all patients presented with SAH-associated IPH at admission. Despite the presence of such negative prognostic factor and the poor condition at admission, a high rate of favourable outcome and QOL was observed, therefore justifying aggressive surgical treatment.