The authors have nicely presented a rare case of extracranially originating posterior inferior cerebral artery (PICA) harboring a saccular aneurysm, which caused intraventricular hemorrhage after rupture.[1] They have correctly emphasized the importance of visualization of the upper cervical region in cerebral angiograms to look for aberrantly originating PICAs. PICA has the most variable course and origination among the cerebral vessels.[2] It may originate extracranially and even extradurally from the vertebral artery. Aneurysms of the proximal segment of this artery are more common than those of the distal segment. When these aneurysms bleed, the clinico-radiological picture might be quite perplexing to the physician. Extracranial location of the ruptured PICA aneurysm might give rise to subarachnoid hemorrhage localized to the anatomical region of cisterna magna which is difficult to diagnose. Yet, it is quite common to see intraventricular hemorrhage after the rupture of such aneurysms which is caused by the jet of blood entering the 4th ventricle through the foramina of Luschka and Magendie; such a hemorrhage may even reach the supratentorial ventricles (as is with the present case). This is a very important clue to the diagnosis and should make the vigilant physician to ask for a thorough angiographic study to rule out such hemorrhagic lesions.[3] The traditional rule of “adequacy” of a four-vessel cerebral angiography still makes sense and leads to correct diagnosis. The origin of both PICAs should be visible in an “adequate” cerebral angiogram which precludes missing of these elusive lesions from diagnosis.