We report a case of ruptured distal posterior inferior cerebellar artery (PICA) aneurysm with large hematoma in the fourth ventricle that was treated by endovascular therapy after endoscopic evacuation of the hematoma. A 65-year-old man presented with a deep coma and was transferred to our hospital. Computed tomography (CT) scan revealed a large hematoma in the fourth ventricle. CT angiography did not demonstrate any aneurysms. Thereafter, emergent endoscopic evacuation of the hematoma was

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... rmed to relieve brain stem compression and hydrocephalus. Cerebral angiography was done immediately after the operation, and a distal PICA aneurysm was detected. The aneurysm was treated by coil embolization. The patient was able to walk with a cane and was discharged after undergoing rehabilitation for seven months. Coil embolization after endoscopic evacuation of hematoma may improve the outcome of patients with large cerebellar hemorrhage caused by ruptured aneurysm.