OBJECTIVE Treatment of middle cerebral artery (MCA) aneurysms remains controversial because of their morphological characteristics. The aim of our study was to analyze the morbidity, mortality, and outcome of patients who underwent clipping of MCA aneurysms and compare with that of endovascular therapy. METHODS Patient and aneurysm characteristics and treatment outcomes of patients treated by the senior author from 1992 through 2012 were analyzed. Various factors associated with good outcome were analyzed. RESULTS One hundred twenty-five patients with 132 aneurysms were included in the study. Seven patients had bilateral MCA bifurcation aneurysms, and 11 were giant aneurysms. Ninety-two point four percent aneurysms were located at MCA bifurcation, others being at pre- or post-bifurcation segments of M1. Intraoperative rupture was encountered in 4.8%. The overall perioperative morbidity and mortality was 8% and 0.8%, respectively. At a mean follow-up of 19.3 months, 83.8% patients had good outcome (mRS 0 and 1). The angiographic obliteration rate at one-year follow-up was 98%. Good preoperative Hunt and Hess grade and unruptured aneurysm were significantly associated with good outcome, whereas presence of hematoma was associated with poor outcome following surgery (P less than 0.05). CONCLUSIONS The results of clipping of MCA aneurysms are superior to that of published endovascular therapy. Surgical clipping remains the standard of care for MCA aneurysms with good clinical and angiographic outcome.