| Summary: | Background: Giant serpentine aneurysms are rare with only ~60 aneurysms being described in the literature. Various treatment modalities have been employed to treat these complex entities including endovascular and complex surgical methods with a range of treatment strategies including vessel sacrifice, trapping, and bypass. Complex treatment strategies are determined preoperatively with little attention given to intraoperative monitoring techniques that could affect intraoperative decision tree analysis and change operative treatment management in real time to improve outcome. Case description: An elderly woman with significant comorbidities presented with an incidental, unruptured, giant serpentine middle cerebral aneurysm with associated saccular aneurysms and scheduled for open surgical approach with superficial temporal artery bypass with clipping and trapping. The presurgical plan was aborted after intraoperative neuromonitoring techniques demonstrated stable neuromonitoring functionality and bypass was aborted for simple trapping of saccular and serpentine aneurysms resulting in real-time surgical decision tree analysis. Conclusion: Use of continuous neuromonitoring techniques are crucial for the real-time surgical assessment of intraoperative therapies that can affect the surgical decision tree analysis and approach to simplify surgery, limit unnecessary procedures, and improve surgical outcome. Keywords: Giant serpentine aneurysm, Intraoperative microscopic Indocyanine-green angiography, Intraoperative neuromonitoring, MEPs
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