Objectives: Surgical management of aneurysmal sub arachnoid haemorrhage has declined with the development and advances in endovascular techniques. Bypass surgery is reserved for a small number of cases where vessel sacrifice is required and would result in a clinically significant infarct. We present a case of a patient requiring a PICA-PICA (Posterior Inferior Cerebellar Artery) bypass and review literature for the use of this rare neurovascular procedure.

Methods: A 58 year old gentleman presented with a clinical and radiological diagnosis of subarachnoid haemorrhage. CT Angiogram and Digital Subtraction Angiogram confirmed the presence of a fusiform aneurysm of the proximal PICA. The angiogram confirmed the PICA vessel to be the dominant supply to the left cerebellar hemisphere with no cross filling from the right.

Results: A successful PICA-PICA bypass was performed followed by an immediate post-operative angiogram which showed adequate perfusion of bilateral PICA territories with a right vertebral injection. The left PICA aneurysm was then coiled sacrificing the vessel. Post-operatively the patient made a good clinical recovery with no significant neurological deficit.

Conclusions: Intracranial-Intracranial bypass surgery, although technically challenging, should be considered in select patients and can provide a useful adjunct to vessel sacrifice to minimise the risk of post-intervention infarct.