Background The combined approach to complex brain МСА aneurysm seems to be generally considered viable. Although it is fairly common, the combinations of modalities, which are suggested in different case reports, vary significantly. This case discusses a sequential approach of reconstructive microsurgery with internal maxillary-to-middle cerebral artery bypass followed by the balloon test occlusion and endovascular embolization of the aneurysm and the MCA. The combined approach together with use of maxillary artery helped minimize the intraoperative and postoperative complications. Case presentation A 62-year-old female with rare episodes of headache and depression revealed giant middle cerebral artery aneurysm. The patient underwent a combined operation in a hybrid operating room with no serious neurologic deficit after surgery. Conclusions Multimodality management in a hybrid operating room should be considered in case of complex fusiform aneurysm of MCA, which is associated with high risks of clipping. Thus, the sequential procedures will improve patient outcomes in treatment of complex МСА aneurysms.

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