Hydrocephalus can commonly present in these patients. This may be due to obstruction of the cerebrospinal fluid pathways by intraventricular or subarachnoid hemorrhage, or to extrinsic compression of the fourth ventricle by a posterior fossa hematoma. Hydrocephalus acts to increase intracranial pressure, and is surgically treated by drainage of cerebrospinal fluid. In the acute stages this is usually by placement of an external ventricular drain through a frontal burr hole. Although some types of communicating hydrocephalus can be treated by lumbar drainage, this is not possible with an intracerebral hematoma because of the danger of increasing brain shifts and herniation.

In the moribund patient an external ventricular drain can be inserted under local anesthesia, but in any case preoperative preparation follows the general pattern described elsewhere, with the use meanwhile, if appropriate, of medical measures to reduce intracranial pressure.

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