Objective To study the value of configuration of the fourth ventricle to indicate, surgical treatment in patients with spontaneous cerebellar hemorrhage. Methods The data of 52 patients with spontaneous cerebellar hemorrhage were retrospectively analyzed. The relationship between configuration of the fourth ventricle and consciousness, volume of the hematoma, frequence of hydrocephalus and incidence of deterioration of consciousness was investigated. Results The correlations between the degree of the fourth ventricular compression and the consciousness, the volume of the hematoma were strong (r= -0.881,P <0.01; r=0.808,P < 0.01, respectively). The more the degree of the fourth ventricular compression was severe,the more GCS score was low and the volume of the hematoma was large. The incidence of hydrocephalus in patients with composed the fourth ventricle[57.7%(15/26)] was significantly higher than that in patients with normal configuration of the fourth ventricle [16.7% (3/18)] (χ~2= 7.406, P < 0.01). The incidence of deterioration of consciousness in patients with compressed the fourth ventricle who accepted conservative therapy initially [72.7% (8/11)]was significantly higher than that in patients with normal configuration of the fourth ventricle [12.5%(2/16)] (P= 0.003). Conclusions The configuration of the fourth ventricle is an useful indicator for surgical treatment in patients with spontaneous cerebellar hemorrhage. When making decision whether surgical treatment was used or not in patients with spontaneous cerebellar hemorrhage, the configuration of the fourth ventricle should be take into account.