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Background: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country. Methods: This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes. Results: From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0–9). Median age was 55 years (interquartile range 46–62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03–1.08), hypertension (adjusted OR 1.81, 95% CI 1.04–3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85–8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31–6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32–4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81–5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13–7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42–5.05). Conclusions: Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil. [ABSTRACT FROM AUTHOR]