Patients with untreated giant intracranial aneurysms have a dismal prognosis as a result of hemorrhage, cerebral compression, and thromboembolism. Therefore, giant aneurysms should be treated. The operative approach is chosen to maximize exposure of the aneurysm. Direct clipping of the aneurysm neck, with preservation of the parent and branch vessels, is the preferred method of occlusion. Hypothermic circulatory arrest may facilitate clipping in selected patients. Alternative techniques for unclippable aneurysms can be utilized, but they compromise parent arteries and require revascularization to maintain CBF. Because mass effect is an important cause of patient morbidity, giant aneurysms are usually debulked after they have been eliminated completely from the circulation. Giant aneurysms are complex lesions that demand thorough surgical planning, individualized strategies, and a multidisciplinary effort.