Making an appropriate diagnosis and administering effective treatment for hydrocephalus in patients with severe disorders of consciousness (DOC) remains controversial and difficult. Given that the typical symptoms are usually concealed by the limited behavioral responsiveness of patients with severe DOC, hydrocephalus diagnosis is likely to be missed in the clinic. Even if not, the presence of hydrocephalus may reduce the likelihood of DOC recovery, posing a conundrum for clinicians. From December 2013 to January 2023, the clinical data and therapeutic schedule of hydrocephalus in patients with severe DOC at Huashan Hospital's Neurosurgical Emergency Center were studied retrospectively. Sixty-eight patients (mean age [± SD] 52.53 ± 17.03 years, 35 males and 33 females) with severe DOC were included. The hydrocephalus was discovered after computed tomography (CT) or magnetic resonance imaging (MRI) revealed enlarged ventricles in the patients. During hospitalization, patients underwent a surgical treatment that included a ventriculoperitoneal (V-P) shunt and/or cranioplasty (CP) implantation. Following the surgery, an individualized V-P pressure was established based on the patient's ventricle size and neurological function variation. To account for the improvement in consciousness in patients with severe DOC, Glasgow Coma Scale (GCS) and Coma Recovery Scale-Revised (CRS-R) assessments were performed before and after hydrocephalus treatment. All patients with severe DOC had varying degrees of ventricular enlargement, deformation, and poor brain compliance. Approximately 60.3% (41/68) of them had low- or negative-pressure hydrocephalus (LPH or NegPH). Of the patients, 45.5% (31/68) had a one-stage V-P shunt and CP operation performed concurrently, whereas the remaining 37 patients had a single V-P shunt operation performed independently. Besides two patients with DOC who developed surgical complications, 92.4% (61/66) of the survivors showed an improvement in consciousness after hydrocephalus treatment. In patients with severe DOC, LPH or NegPH was common. Secondary hydrocephalus in patients with DOC had been largely ignored, hampering their neurological rehabilitation. Even months or years after the onset of severe DOC, active treatment of hydrocephalus can significantly improve patients' consciousness and neurological function. This study summarized several evidence-based treatment experiences of hydrocephalus in patients with DOC.