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Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) are considered to have a poor prognosis. However, the underlying reason for the association between the aneurysmal characteristics and poor-grade aSAH is still unclear. In the present study, we retrospectively evaluated the independent risk factors for patients with anterior communicating artery (ACoA) aneurysms with poor-grade aSAH. From January 2009 to January 2016, 477 consecutive patients with ruptured ACoA aneurysms were included in the present study. Poor-grade aSAH was defined as a World Federation of Neurosurgical Society grade of IV or V, and good-grade aSAH was defined as a grade of I–III. Univariate and multivariable regression analyses were used to investigate the differences in aneurysm morphology and clinical characteristics between the 2 groups. On univariate analysis, older patients (P = 0.038), larger aneurysm size (P = 0.013), larger size ratio (P = 0.007), larger aspect ratio (P = 0.009), positive history of stroke (P = 0.001), and posterior projection aneurysms (P = 0.001) were associated with poor-grade aSAH. Multivariate analyses revealed that older patients (odds ratio [OR], 1.654; 95% confidence interval [CI], 1.004–2.728; P = 0.048), larger size ratio (OR, 1.280; 95% CI, 1.111–1.475; P = 0.001), positive history of stroke (OR, 6.051; 95% CI, 1.712–21.381; P = 0.005), and posterior projection aneurysms (OR, 2.718; 95% CI, 1.607–4.598; P < 0.001) were independently associated with poor-grade aSAH. Poor-grade aSAH was independently associated with older patients, a larger size ratio, a positive history of stroke, and posterior projection aneurysms in patients with a ruptured ACoA aneurysm. These parameters could contribute to screening for patients with the potential for poor-grade aSAH. [ABSTRACT FROM AUTHOR]