A 51-year-old male was hospitalized in our department following sudden onset of a left hemiparesis. The cerebral computed tomography (CT) and the computed tomographic angiogram (CTA) scans, carried out at admission, showed a right giant MCA aneurysm without subarachnoid hemorrhage (SAH) but with mass effect []. The baseline cerebral angiography confirmed the presence of a giant aneurysm (about 20 × 30 mm with the largest perpendicular diameters in the anteroposterior projection) at the MCA bifurcation. The vascular flow through the MCA was very slow and its contrast opacification was delayed with respect to the ipsilateral anterior cerebral artery (ACA) by 1.75 s []. No embolic occlusions were seen. Angiographic images of the left carotid artery and vertebro-basilar complex were normal. At admission, an antiedema therapy with dexamethason was administered, which favoured the almost complete recovery of the symptoms within a few days. With the aim of avoiding any interruption of the bood flow, we decided to perform a combined therapeutic strategy with stenting and surgery. The stenting would protect the MCA and its branches during the surgical maneuvers of dissection and clipping of the aneurysm. On the day of surgery under general anesthesia in the radiology unit, an Enterprise stent (4.5 × 37 mm) (Cordis Neurovascolar, Miami Lakes, Florida, USA) was first placed from the right carotid dichotomy to the proximal M2 segment of the inferior trunk. Afterwards a flow diverter Silk stent (2.5 × 15 mm) (Balt, Montmorency, France) from the distal M1 segment to the proximal M2 segment of the inferior trunk was placed to complete the coverage of the aneurysmal neck. No stent was placed in the M2 superior thinner trunk of the right MCA. At the end of the endovascular procedure, an angiogram was performed, which showed a major staunching of blood within the sac, patency of the MCA, and the correct position of both stents []. At this point, the patient was moved to the neurosurgical operating room, where a standard pterional approach was performed. Once the sylvian fissure was opened, the aneurysm was immediately visible. Both the M2 trunks of the MCA were seen firmly adhered to the sac. The inferior trunk was larger and the flow diverter Silk stent was visible through the transparency of the arterial wall. Stenting had made the vessel stiffer, easing significantly surgical manipulation during the dissection and also preventing arterial spasms. After freeing the M2 superior trunk [], the aneurysmal neck has been exposed and multiple clips were applied. Because of the consistency of the neck, the first clip tended to slip on the neck, wich in effect was protected by the stent. Three clips and the opening of the aneurysm were necessary to collapse the sac, which was then resected []. Despite the previous stenting, abundant bleeding occurred during the emptying of the sac. As expected, the patency of the vessels ramained protected by the stents during the entire surgical phase. After surgery the patient remained in the intensive care unit for 2 days. Upon awakening, he showed a moderate left hemiparesis, which improved 3 weeks after surgery. A postoperative CT showed hypodensity around the surgical field []. Cerebral angiography monitoring at 1-year showed the complete exclusion of the aneurysmal sac, no delay in the venous phase was seen while optimal flow through both M2 branches was noted []. An important issue is the management of the anticoagulant/antiplatelet therapy. We use a standard protocol for stenting alone or with coiling as follows: 5 days of double antiplatelet theraphy before the procedure with acetylsalicylic acid (100 mg once daily) and clopidrogel (75 mg once daily), a bolus of 5000 UI of heparin at benning of the treatment followed by 1000 UI of heparin hourly during the procedure. After that, we administer both antiplatelet drugs for the first 3 months and then only acetylsalicylic acid for the following 2 months after the procedure at dosages reported in the pretreatment regimen. In this case, we decided to modify the standard therapy on the days before and on the day of combined treatment. Three days before the combined treatment, prophylaxis with heparin, started at admission, was interrupted and antiplatelet therapy only with acetylsalicylic acid (100 mg once daily) was administered orally. On the day of combined treatment, a double pharmacological antiplatelet therapy was administered. Acetylsalicylic acid (100 mg once daily) was administered before the stenting and clopidrogel (75 mg once daily) just after closing the duramater. No bolus of heparin was administered at the beginning of endovascular procedure. However, as in all endovascular procedures, all pressure washing systems were fully heparinized. One day after surgery, the patient started with the standard therapy with both antiplatelet drugs for the first 3 months and then with acetylsalicylic acid only for the following 2 months at the usual dosages. No particular problems of immediate or later bleeding with the wound was managed in this case.