Middle cerebral artery aneurysms represent a significant proportion of intracranial aneurysms and pose important challenges in neurovascular management because of their complex anatomical configuration and variable morphological characteristics. These aneurysms frequently arise at the bifurcation of the middle cerebral artery, where hemodynamic forces and vascular geometry contribute to aneurysm formation and progression. Factors such as aneurysm size, neck width, vessel branching, and local blood flow dynamics influence both rupture risk and treatment selection. Understanding these anatomical and pathophysiological mechanisms is therefore essential for optimizing therapeutic strategies. Microsurgical clipping and endovascular therapy represent the two principal treatment approaches for middle cerebral artery aneurysms. Microsurgical clipping involves the direct exclusion of the aneurysm from the cerebral circulation through clip placement across the aneurysm neck. This technique has demonstrated high rates of complete aneurysm occlusion and long-term durability, particularly in wide-neck or complex aneurysms. However, it is associated with greater surgical invasiveness and a higher risk of perioperative morbidity. In contrast, endovascular therapy aims to exclude the aneurysm from the circulation through catheter-based techniques such as coil embolization, balloon-assisted coiling, stent-assisted coiling, and flow diversion. These approaches are less invasive and are often associated with shorter hospital stays and improved short-term functional outcomes. Nevertheless, endovascular therapy may present higher rates of aneurysm recurrence and the need for retreatment. Current evidence suggests that both treatment modalities achieve comparable overall clinical outcomes, although their advantages differ depending on aneurysm morphology and patient characteristics. As advances in surgical and endovascular techniques continue to evolve, the management of middle cerebral artery aneurysms increasingly relies on individualized treatment selection supported by multidisciplinary neurovascular teams.