We present surgical clipping of a giant middle cerebral artery aneurysm. The patient is a 64-year-old woman who suffered subarachnoid hemorrhage in 2005. She was treated with coiling of the aneurysm at an outside institution. She presented to our clinic with headaches and was found on angiography to have giant recurrence of the aneurysm. To allow adequate exposure for clipping, we performed the surgery through a cranio-orbito-zygomatic (COZ) skull base approach, which is demonstrated. The surgery was performed in an operating room/angiography hybrid suite allowing for high quality intraoperative angiography. The technique and room flow are also demonstrated.