Giant intracranial aneurysms often pose difficult management issues. Such aneurysms may not be amenable to direct surgical attack because of their size, location, or lack of a clear aneurysmal neck. In such cases, a combination of strategies may provide a means of proximal aneurysm occlusion and distal cerebral revascularization. The authors report the successful treatment of a giant (186.8-ml) serpentine aneurysm of the left middle cerebral artery (MCA) in a 14-year-old boy. The aneurysm was managed in a two-stage procedure in which the MCA branches distal to the aneurysm were anastomosed first with branches of the left superficial temporal artery. After the bypass procedure, direct occlusion of the MCA was performed at the proximal base of the aneurysm at its site of dilatation. The patient had no intraoperative or postoperative complications and was intact neurologically 6 months following the procedures.