Advances in the endovascular treatment of intracranial aneurysms since the advent of detachable coil embolization continue to expand the spectrum of lesions amenable to minimally invasive therapy. The feasibility of treating a given cerebral aneurysm by a given open or endovascular modality does not necessarily make such an approach the optimal choice. Rather, any given cerebral aneurysm and patient should be carefully analyzed on a multitude of parameters which are based on available adjunctive technology, aneurysm morphology and characteristics, endovascular vs. microsurgical accessibility, and long-term angiographic outcome. In addition to patient age, co-morbid conditions, lesion size and attendant risk, one must also consider patient preference with respect to length of hospital stay, recovery duration and required follow-up and radiographic assessments. The relentless improvements in minimally invasive embolization therapies ranging from coiling with adjunctive balloon and stent support to the emerging role of flow-diversion must be balanced against the lower cost and complexity associated with longitudinal clinical and radiographic follow-up requirements of microsurgical clipping. This review will consider the various factors involved in the determination of optimal modality choice based on an assessment of clinical, morphological and anatomical considerations. In this rapidly evolving field, the quest for maximizing protection from aneurysm rupture at the lowest neurological cost dictates that a balance be maintained between technical virtuosity and procedural safety of either microsurgical clipping or endovascular repair to insure that the advantages of the selected modality not be negated by its associated shortcomings.