The management of fusiform anterior circulation aneurysms has been controversial, due to the rare nature of such lesions. They provide a unique management challenge compared to saccular aneurysms, and a variety of microsurgical techniques have been attempted in the past, with varying success rates. Fusiform middle cerebral artery aneurysms can be fraught with morbidity and even mortality, if perforator ischaemia results from intervention. In this neuroendovascular era, flow diverters have shown promise in both securing the aneurysm and minimising neurologic deficits associated with treatment.