Abstract： Objective To explore the clinical characteristics and surgical managements of posterior inferior cerebellar artery (PICA) aneurysms. Methods Retrospective analysis of the clinical features, imaging characteristics and clipping results of 21 PICA artery aneurysms. This series included 9 men and 12 women, mean age was 40.6 years. One presented with mass pressure effects of infrotentoria fossa; 20 patients presented with severe and sudden onset of symptoms, reflecting a hemorrhage from a PICA aneurysm. Hunt-Hess and Hess grades at presentation were: Grade Ⅰ in 1 patient, Grade Ⅱ in 14 patients, Grade Ⅲ in 5 patients, Grade Ⅳ in 1 patient. The bleeding was confined to the infrotentoria subarachnoid space (SAH) and/or the fourth ventricle. Arteriographies revealed 13 proximal PICA aneurysms and 8 distal PICA aneurysms. Results Lateral suboccipital and midline suboccipital surgical approaches were used to secure the aneurysms in all patients, either by direct clipping in 19 cases, parent artery's occlusion in 1 case and parent artery's sacrifice in 1 case. Transient CSF leak occurred in 3 patents; paresis and lower cranial nerve dysfunction and long-term coma occurred in 1 patient; mild lower cranial nerve dysfunctions occurred in 2 patients, and had good recovery at 3 months of follow-up; no complication in other patients. Conclusions The favorable outcomes and low postoperative morbidity in our patients argues that surgical clipping be considered a first-line therapeutic option. The protection of the low cranial nerves and the preservations of PICA are major contributors to good long-term results.