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We investigated long-term outcome of 6 patients with a large or giant aneurysm of the vertebral artery. Patients were 4 men and 2 women, aged from 26 to 74 (mean 56) years old. Only 1 patient presented with subarachnoid hemorrhage, whereas 3 patients presented with signs of brain stem compression and 2 patients with headache. Aneurysms were 18 to 40 (mean 26) mm in maximum diameter and 5 of them were thrombosed in various degrees. Three patients underwent direct surgery (neck clipping+aneurysmectomy, trapping, coating) and 3 patients were treated conservatively at initial presentation. The latter 3 patients developed deterioration of neurological symptoms and enlargement of the aneurysm within the following 4 to 6 years, and thus 2 patients underwent surgery (neck clipping+aneurysmectomy, endovascular parent artery occlusion). One month after endovascular surgery, however, 1 of the patients died of rupture of aneurysm. Long-term outcome in GOS was as follows: GR (2), SD (1), and D (3). Two patients with GR underwent direct surgery via transcodylar approach at initial presentation for aneurysms less than 30 mm in size. Although difficult in many cases, neck clipping or trapping with aneurysmectomy via the cranial base approach, before enlarging to “untreatable” size, is the best therapeutic strategy for these aneurysms. On the contrary, long-term outcome of patients with conservative treatment was poor.