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Background Treatment of large complex cerebral aneurysms remains clinically challenging due to high rates of recurrence and procedural complications associated with conventional coiling or surgical clipping. Recently, flow diversion (FD) has emerged as a compelling therapeutic alternative, offering high rates of complete occlusion and long-term parent artery remodeling by endoluminal reconstruction.Methods A 61-year-old female presented with an incidentally discovered large fusiform complex aneurysm located at the left middle cerebral artery (MCA) M1 bifurcation, involving both the superior and inferior M2 trunks. Given the complex anatomy and size of the lesion, endovascular treatment using a flow diverter was selected. Under general anesthesia, a distal access catheter (AXS Catalyst, 115 cm) was navigated to the target site to provide stable support. Using a microcatheter (Excelsior XT-27), a flow-diverting stent (Surpass, 3.25 mm x 25 mm) was carefully delivered and deployed across the aneurysm neck, extending from the M2 superior trunk to the proximal M1 segment. The procedure aimed to achieve flow redirection while preserving the patency of the involved M2 branches.Results Post-procedural angiography demonstrated an immediate flow reduction within the aneurysm sac, categorized as O’Kelly-Marotta (OKM) Scale Grade B (subtotal stasis). A follow-up brain CT performed shortly after the procedure showed contrast stagnation within the aneurysm, while magnetic resonance (MR) diffusion-weighted imaging confirmed the absence of acute infarction, indicating preserved flow in the involved M2 branches. At the 2-month follow-up brain CT angiography (CTA), the aneurysm was completely excluded from the circulation with no visible contrast opacification. Furthermore, the patency of both the superior and inferior M2 trunks was successfully maintained, with no evidence of flow-diverter-related branch occlusion.Conclusion This case demonstrates that flow diversion using the Surpass device can be a safe and effective primary treatment for complex large fusiform MCA bifurcation aneurysms, achieving early occlusion while ensuring branch patency .Disclosures T. Kim: None.