Very large and giant (> or =15 mm) cerebral aneurysms have a poor natural history, with high risk of subarachnoid hemorrhage or progressive symptoms of mass effect. Several endovascular techniques may be applied for treatment, depending on location, size, anatomy and presence of collateral circulation. The authors reviewed their clinical experience in endovascular treatment of 232 very large and giant aneurysms and present their perspective on the present state of the art in endovascular therapy for these aneurysms.