Summary The management of patients with aneurysmal subarachnoid haemorrhage demands expertise to anticipate, recognise, and promptly treat the many neurological and systemic complications. For this reason, these patients are best cared for in high-volume medical centres with multidisciplinary teams and should preferably be treated in a specialised intensive care unit. Endovascular occlusion and surgical clipping provide complementary alternatives for the treatment of aneurysms. Perfusion scans are redefining the way we detect delayed ischaemia as a growing body of evidence indicates that monitoring vessel diameter is insufficient to prevent cerebral infarctions. Statins, endothelin antagonists, and magnesium sulfate infusion are among the novel strategies being tested for neuroprotection and attenuation of vasospasm. The effectiveness of these treatments is supported by strong experimental data and they represent a new generation of therapeutic options developed from the understanding that vasospasm is primarily caused by endothelial dysfunction.