Multiple massive intratumoral hemorrhages of metastatic brain melanoma after ventriculoperitoneal shunt Tsung-Hsi Yang, Jung-Tung Liu, Fook-How Chan Formosan Journal of Surgery 2019 52(3):99-102 A 50-year-old male presented with sudden-onset headache, diplopia, and unsteadiness due to a posterior fossa hemorrhagic melanoma causing hydrocephalus. Computed tomography of the brain showed a 2.3 cm × 2.0 cm hemorrhagic tumor in the cerebellar vermis and a concomitant fourth ventricular hemorrhage. He underwent removal of the tumor and then ventriculoperitoneal shunt insertion for hydrocephalus. Because of his widespread disease, the patient died 2 weeks later from multiple massive intratumoral hemorrhages. To avoid this unfortunate consequence, we discuss the mechanism and suggest methods for treatment improvement. The variable we could control carefully was the opening pressure of the shunt and the flow of cerebrospinal fluid drainage. Setting a higher opening pressure and changing the pressure more slowly should be considered. To achieve this goal, the use of a programmable valve and anti-siphon system should strongly be recommended in these high-risk populations with extremely high bleeding tendency.