This clinical case details the management of a 72-year old female patient who developed cerebellar hemorrhage and hydrocephalus following systemic and intra-arterial thrombolysis for a middle cerebral artery embolism. The article provides a step-by-step video demonstration of placing an external ventricular drain to relieve hydrocephalus, followed by suboccipital craniotomy and evacuation of the cerebellar hematoma. Emphasis is placed on surgical techniques, anatomical landmarks, potential complications, and postoperative care. This case highlights the critical role of timely intervention in hemorrhagic transformation after stroke to improve neurological outcomes.