Abstract: Anterior communicating artery aneurysms are among the most commonly encountered ruptured aneurysms. Both endovascular and microsurgical treatment should be considered. Their complex anatomy makes microsurgical treatment challenging, a concern that is amplified in the setting of subarachnoid hemorrhage. Nonetheless, many will still require microsurgical treatment. Small aneurysms and those with a broad neck are particularly likely to need microsurgical treatment. Posteriorly projecting aneurysms or those that present in patients who have high medical risk for surgery should be favored for an endovascular approach. This chapter reviews the diagnostic and therapeutic considerations in the management of ruptured anterior communicating artery aneurysms, including the selection of surgical approach based on aneurysm anatomy.