Awake fiberoptic intubation (AFOI) has the potential to trigger hypertension, tachycardia and hypoxia or hypercarbia. Patients who require fiberoptic-guided endotracheal intubation for the clipping or coiling of an intracranial aneurysm pose particular challenges for the safe completion of both procedures. This chapter presents a case study of a 56-year-old female with a poorly documented history of difficult intubation presented for elective clipping of a middle cerebral artery aneurysm. The case discussion highlights the considerations for awake endotracheal intubation in the patient with an unsecured aneurysm. The indications for AFOI in this case are essentially the same as for any difficult airway: concern for the ability to visualize the glottic opening via direct laryngoscopy combined with concern for the ability to mask ventilate. Hypercarbia or hypoxia during an awake fiberoptic intubation are frequently due to loss of respiratory efforts in a narcotized patient.