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We report a patient with rupture of a giant distal vertebral artery aneurysm after balloon occlusion of the parent vertebral artery. We were able to occlude the residual lumen by endosaccular embolization and trapping with Guglielmi detachable coils via the anterior circulation. We suspect that either alterations in flow patterns or partial thrombosis of the aneurysm may have contributed to at least two subarachnoid hemorrhages within 2 days after the initial embolization. We still considered endovascular parent vessel sacrifice to be an excellent therapeutic option, particularly in distal vertebral aneurysms. We recommend a detailed evaluation of angiographic flow patterns and aneurysm patency during test occlusion. If the aneurysm continues to fill from the collateral circulation, or if marked alterations in flow patterns are present, aneurysm trapping or concurrent endosaccular embolization and parent vessel sacrifice may be necessary. Certainly, continued surveillance is required as long as any residual aneurysm is present.