Objective: Saccular aneurysms of the basilar artery (BA) trunk are a significant challenge in neurosurgery due to their rarity and the complexity of surgical approaches. This study examines the efficacy and outcomes of microsurgical treatment for these aneurysms, highlighting the advantages over endovascular methods in terms of occlusion rates and complication management. Methods: A retrospective review of 23 patients with BA trunk aneurysms treated microsurgically at the Moscow Regional Clinical Research Institute from June 2019 to April 2024 was conducted. Patient demographics, aneurysm characteristics, surgical techniques, and postoperative outcomes were analyzed. Results: The study group included 16 women and 7 men, with an average age of 51.2 years. Notably, 19 of 23 patients (82.6%) presented with subarachnoid hemorrhage (SAH), while 4 had unruptured aneurysms (2 asymptomatic, 2 with mass effect). Aneurysms were predominantly located at the origin of the superior cerebellar artery (SCA). Surgical approaches varied based on aneurysm location, with most utilizing the orbito-pterional approach. Complete occlusion was achieved in all cases and was maintained over the follow-up period without signs of recanalization. Complications included transient oculomotor nerve dysfunction in 5 patients, with a substantial recovery rate. Favorable outcomes (mRS 0–2) were achieved in 87% of patients, including most SAH cases, highlighting the safety and effectiveness of treatment. Conclusions Microsurgical treatment of BA trunk aneurysms provides a reliable occlusion with a low rate of complications and excellent clinical outcomes. This series supports microsurgery as a preferred option for managing these challenging aneurysms, particularly when located at the SCA origin.