A 36-year-old male presented with headache, vomiting, and gait disturbance. Examination found marked anemia, renal failure, markedly choked disks, and hypertensive encephalopathy. Magnetic resonance imaging demonstrated diffuse swelling of the brainstem and cerebellum, and obstructive hydrocephalus. Treatment with steroid, glycerol, and antihypertensive drugs resulted in a slow decrease in the brain swelling and cerebral edema. However, hydrocephalus and intracranial hypertension persisted, requiring a shunt operation. Hypertensive encephalopathy is usually improved by the treatment of hypertension, but shunt operation may be required to treat exacerbated intracranial pressure associated with obstructive hydrocephalus.