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Object: Hydrocephalus is one of the main complications of brain tumors in children, being present in about 50% of cases at the time of the tumor diagnosis and persisting up to 10–40% of cases after surgical resection. This is a single-institution retrospective study on the variables that may predict the need for treatment of persistent hydrocephalus in pediatric patients presenting with a brain tumor. Methods: Retrospective case note review of 43 newly diagnosed brain tumors in children referred between April 2012 and January 2018 to our regional pediatric neuro-oncology service was carried out. Diagnosis of hydrocephalus was carried out using both preoperative and postoperative MRI to determine Evans’ index (EI) and the fronto-occipital horn ratio (FOHR) from each scan. Simple logistic regression was used to analyze categorical variables as appropriate. A p value Results: Forty-three children were analyzed, 26 males and 17 females with a median age at diagnosis 10.4 years (IQR: 5.2–13.5). Hydrocephalus was present in 22/43 children (51%) preoperatively; in 8/22 children (36%) with hydrocephalus undergoing tumor resection, hydrocephalus persisted also in the postoperative period. An EI >0.34 (p = 0.028) and an FOHR >0.46 (p = 0.05) before surgery were associated with a higher prevalence of persistent hydrocephalus and therefore to the need for a cerebrospinal fluid drain device in the postoperative phase. Conclusion: Preoperative identification of children at risk for developing persistent hydrocephalus would avoid delays in planning the permanent cerebrospinal fluid drain devices. This study finds that an EI >0.34 and an FOHR >0.46 at diagnosis could impact on the therapeutic management of children with hydrocephalus associated with brain tumors. Prospective and larger-scale studies are needed to standardize this approach.