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OBJECTIVE This study aims to assess whether the A1 segment hypoplasia is a risk factor for unfavorable radiologic and clinical outcomes of surgical clipping anterior communicating artery (ACoA) aneurysm. METHODS We retrospectively reviewed 251 patients with ACoA aneurysm who underwent surgical clipping in Beijing Tiantan Hospital between September 2011 and September 2016. Their clinical and radiologic features, as well as clinical outcomes, were reviewed. In addition, univariate and multivariate logistic regression analysis was performed to identify independent risk factors for the postoperative infarction and unfavorable clinical outcomes of surgical clipping ACoA aneurysm. RESULTS The incidence of A1 segment hypoplasia was 49.8% (125 of 251 patients). Univariate analysis showed that multiple aneurysm (P = 0.025), diameter of aneurysm (P = 0.040), and A1 segment hypoplasia (P = 0.010) were associated with anterior cerebral artery (ACA) territories infarction, and A1 segment hypoplasia (P = 0.002) is significantly correlated with unfavorable clinical outcomes of surgical clipping ACoA aneurysm. Moreover, multivariate analysis showed that multiple aneurysm (P = 0.038; odds ratio [OR], 2.571), diameter of aneurysm (P = 0.034; OR, 1.097), and A1 segment hypoplasia (P = 0.007; OR, 3.619) were strongly independent risk factors for ACA territories infarction. In addition, Hunt and Hess scores (P = 0.036; OR, 2.326) and A1 segment hypoplasia (P = 0.002; OR, 2.873) are significant independent risk factors for unfavorable clinical outcomes of surgical clipping ACoA aneurysm. CONCLUSIONS A1 segment hypoplasia is a significant independent risk factor for unfavorable clinical outcomes of surgical clipping ACoA aneurysm and ACA infarction after surgery.