Paroxysmal sympathetic hyperactivity (PSH) is a rare complication of hemorrhagic stroke, thus, it could be easily misdiagnosed and overlooked. The clinical data of four PSH cases after hemorrhagic stroke were retrospectively analyzed. Patient 1, patient 3 and patient 4 suffered from severe aneurysmal subarachnoid hemorrhage. Patient 2 suffered from intracerebral hemorrhage with a large hematoma. PSH of patient 1 was related to a hematoma located in right frontal and insular lobe. PSH of patient 2 was related to a huge cyst which occupied right frontal, parietal, temporal and insular lobe, and right basal ganglia. In the case of patient 3, PSH was associated with cerebral herniation and the compressed midbrain. PSH of patient 4 was strongly related to the development of hydrocephalus. The PSH episodes of all patients responded well to sedation and analgesia treatment, or surgical treatment which could reduce the intracranial pressure, such as drainage or shunt. These cases indicate that both the structural and functional disconnection in insular lobe, diencephalon or brainstem within the central autonomic network could result in the development of PSH. Therefore, patients with lesions in these brain regions should be paid attention to the development of PSH.