In some vertebral aneurysms, especially those involving the posterior inferior cerebellar artery (PICA), it is impossible to clamp the aneurysm and ensure the patency of the posterior inferior cerebellar artery at the same time, so it is necessary to perform occipital artery anastomosis of PICA. Because of the low incidence, surgical difficulty and high treatment risk, there are few reports in the literature…We now report the following cases of vertebral artery aneurysm with occipital artery PICA anastomosis plus isolated aneurysm resection admitted to the Department of Neurosurgery of Beijing Sanbo Brain Hospital from January 2008 to August 2009, with regard to the key points of surgery and prevention and treatment of complications, together with the literature.