The posterior inferior cerebellar artery (PICA) is the largest branch of the vertebral artery. It usually arises at the anterolateral margin of the medulla oblongata close to the lower cranial nerves. The PICA had the most complex relationship to the cranial nerves of any artery and it is frequently exposed in approaches directed to the fourth ventricle. The aim of this article is to describe the anatomical relationship of the PICA to the lower cranial nerves. In this study, 12.5% of PICAs passed between the glossopharyngeal and vagus nerves, 20% between the vagus and accessory nerves, and 65% through the rootlets of the accessory nerve. The lateral medullary segment of the PICA showed a lateral loop which in 20% specimens pressed against the inferior surfaces of the facial and vestibulocochlear nerves. The lateral medullary segment of the PICA in 20% specimens passed superior to the hypoglossal nerve, in 47.5% through the rootlets of the hypoglossal nerve, and in 30% inferior to the hypoglossal nerve. The findings on the relationship of the PICA to the lower cranial nerves could be helpful in microsurgery of this region.