Summary:The surgical approaches to aneurysms of the vertebrobasilar arterial complex vary considerably depending on the location, projection, and size of the aneurysm. The surgeon must have a very clear understanding of the local anatomy and any possible variation in the arrangement of vessels encountered. Electrophysiologic monitoring and other adjunctive measures allow safer visualization and direct manipulation of these unusual aneurysms. Endovascular techniques may improve overall management, but they are not fully established. This article reviews our experience with aneurysms of the vertebrobasilar region and emphasizes the need for a complete armamentarium in their surgical management.