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Despite advances in endovascular treatment, microsurgical clipping of middle cerebral artery (MCA) aneurysms remains appropriate. We review the high occlusion rate and treatment durability seen with surgical clipping of MCA aneurysms. We retrospectively reviewed patients who underwent microsurgical clipping of saccular MCA aneurysms by a single surgeon. Outcomes included aneurysm occlusion rate and durability, modified Rankin scale (mRS), and postoperative neurological morbidities. Ninety-two patients with 92 saccular MCA aneurysms were included, 50% of which were ruptured aneurysms. The mean follow-up period was 59 months. Complete aneurysm occlusion was achieved in all except one patient (99%) with near-complete occlusion. MCA aneurysm clipping was durable, with only one patient (1%) requiring retreatment after 4 years due to regrowth. Of the cohort, 79.3% achieved mRS 0–2 at last follow-up, including all with unruptured aneurysms. Poor outcome at discharge was associated with age > 65 (p =.03), postoperative neurological morbidities (p =.006), and aneurysm rupture (p <.001). Older age remained the single correlate for poor long-term outcome (p =.04). For ruptured aneurysms, predictors of poor long-term outcome included hemiparesis on presentation (p =.017), clinical vasospasm requiring treatment (p =.026), and infarction related to vasospasm (p =.041). Older age (p =.046) and complex anatomy (p =.036) were predictors of new postoperative neurological morbidities in the unruptured group. MCA aneurysm clipping is safe, durable, and should be considered first-line treatment for patients with saccular MCA aneurysms, especially in centers with abundant surgical experience. [ABSTRACT FROM AUTHOR]