The occurrence of radiographic hydrocephalus after such an aneurysm rupture reaches 95%. Spontaneous fourth ventricular hemorrhage in the absence or presence of subarachnoid hemorrhage (SAH) requires a vascular study to rule out a PICA aneurysm. As always, the microsurgical experience of the treating clinician plays a central role in the offered choice of therapy. Patients with PICA aneurysms who are older, who have medical morbidities, and who harbor narrow-neck aneurysms should undergo endovascular management whereas young patients and those with wide-neck aneurysms should be considered for microsurgical clipping. Therefore, microsurgery remains a viable option for select patients. The small caliber of the PICA and the broad neck of the associated aneurysms place the PICA at some risk during coil embolization. The tradeoffs between minimally invasive coil embolization versus the more durable clip ligation continue to complicate decision making in aneurysm surgery. The clipping-versus-coiling debate continues to haunt neurosurgeons. Young age of the patient and irregular morphology of the sac all portend a higher rupture risk, and these factors should prompt treatment of aneurysms that are even as small as 5 mm. Nonetheless, most clinicians apply the natural history data from anterior circulation aneurysms to those of the posterior circulation. These studies have not targeted posterior circulation aneurysms adequately, and therefore the true natural history, including the hemorrhagic risk of PICA aneurysms, is unknown. Although natural history studies suggest a very low rupture risk for lesions under 7 mm, the majority of aneurysms that present with hemorrhage are indeed under 7 mm in size this phenomenon presents a conundrum for the neurosurgeon.
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