The treatment of hypertensive cerebral hemorrhage must follow the principle of individualization in order to effectively reduce the mortality and disability rates and improve the overall treatment. The key to surgery is the proper timing of surgery, the appropriate surgical approach and the prevention and treatment of postoperative complications. Surgical treatment of hypertensive cerebral hemorrhage can not only relieve the occupancy effect but also relieve secondary damage to brain tissue caused by hematoma neurotoxic substances. Some studies have shown [1] that there is no significant difference in the prognosis of patients treated surgically versus medically. the randomized controlled study of early surgical treatment versus conservative treatment for supratentorial hypertensive cerebral hemorrhage by Mendelow et al. collected 1033 patients from 83 centers in 27 countries and showed that early surgical treatment, although not a comprehensive advantage over conservative treatment, reduced mortality from massive cerebral hemorrhage and reduced hospitalization time, especially for hematomas closer to the cortex, which can significantly improve patient prognosis. Chen Ming et al [2] used a randomized controlled study with strict selection criteria to exclude factors affecting the outcome as much as possible, such as age, bleeding volume, bleeding site, and complications, and used S-100 protein as an objective index to detect brain injury, and the results showed that the recovery of brain injury was faster in the surgical group than in the conservative group, which provided a basis for the surgical treatment of cerebral hemorrhage. Theoretically, the advantages of ultra-early surgery for cerebral hemorrhage are convincing [3-7]. The hematoma causes acute compression, displacement or disintegration of the surrounding brain tissue and results in impaired circulation and metabolic disorders, which, together with the toxic effects of thrombin, cause a series of pathological changes in the surrounding brain tissue from near to far, including necrosis, perivascular hemorrhage, spongiotic degeneration and cerebral edema. These changes become gradually apparent 6-8 h after the onset of the disease, after which the damage to the brain tissue is irreversible. A study [5] showed that most of the fatal cases of cerebral hemorrhage occurred in the early posthemorrhagic period, so it is advisable to treat surgically in the early posthemorrhagic period (within 7h). Ultra-early surgical treatment can be effective in preventing or delaying the onset of these pathological changes. The cerebral edema within 6-7h of onset is not yet obvious, which facilitates the surgical operation. Therefore, in patients with symptomatic cerebral hemorrhage, the hematoma should be removed as early as possible if conditions permit. The following indications for surgery have been accepted by most people: ① if medical treatment is ineffective, intracranial pressure continues to increase, and the condition continues to worsen without contraindications to surgery, the hematoma should be removed before the brain tissue suffers irreversible damage; ② GCS score ≤13, the patient is in shallow coma or moderate coma, incomplete or complete hemiparesis, and early brain herniation; ③ supratentorial hematoma >30ml, midline structural displacement >1cm, and subatentorial hematoma >1cm. (3) Supratentorial hematoma > 30 ml, displacement of midline structures > 1 cm, subscallosal hematoma > 10 ml, compression of brainstem or fourth ventricle, enlargement of the third and fourth ventricles; (4) Age ≤ 50 years, whose cranial cavity compensatory capacity is poorer compared with older patients (with cerebral atrophy) and surgical tolerance is stronger, and surgical treatment is mostly advocated; (5) Hematoma located in the nucleus accumbens or extending to the pallidum and thalamus via the nucleus accumbens, subcortical p cerebellar and thalamic hematoma breaking into the ventricles. Contraindications: surgery is not considered for those who are aggressive after hemorrhage and fall into coma within a short time. Those with blood pressure ≥200/120 mmHg after the onset of hemorrhage, serious heart, lung and kidney disorders and coagulation disorders are not suitable for surgery. The surgical methods for hypertensive cerebral hemorrhage mainly include: ① direct craniotomy for hematoma removal; ② hematoma puncture aspiration; ③ stereotactic hematoma puncture aspiration; ④ extraventricular drainage for hematoma lysis. Among them, direct craniotomy is divided into bone flap craniotomy and small bone window craniotomy. Brain tissue trauma in bone flap craniotomy is large, brain tissue bulges after debridement, the bulging brain tissue is embedded outside the bone flap, brain tissue ischemia p edema p softening, affecting function [8]. Small bone flap craniotomy is operated under a microscope, with a small trauma and good field of view high hematoma removal rate, exact hemostasis, avoiding accidental damage to the main stem of the doublestem artery and its branches, and minimizing brain damage caused by surgery. Hematoma puncture aspiration and stereotactic hematoma puncture aspiration are simple and less invasive without exposing the brain tissue, and the hematoma is confined to the hematoma cavity and discharged through a hard channel needle, so the hematoma should not spread and has little effect on normal brain tissue and blood vessels. However, the operation cannot be performed under direct vision, and it is somewhat blind to patients with short bleeding time. In addition, it may damage the normal blood vessels and cause rebleeding or hematoma expansion. In our group, three cases of rebleeding after laparotomy were cured by craniotomy. External ventricular drainage hematolysis is suitable for primary intraventricular hemorrhage or hematoma breaking into the ventricle. The ventricle is punctured after cranial drilling or cranial conization, and a drainage tube is placed for external drainage, which can immediately relieve obstructive hydrocephalus and eliminate the fluid part of the hematoma, while reducing the volume of the primary hematoma. If intermittent fibrinolytic drugs such as urokinase are used, the hematoma can be lysed to facilitate drainage. There is an increasing tendency to choose the less invasive approach for surgical treatment. A comparative study of bone flap openings versus bone window openings has found comparable efficacy in the near term, but in the long term follow-up the excellent rate of bone flap openings was found to be 11%, while the small bone window opening was 44.7%. Ultra-early minimally invasive microsurgery for hypertensive cerebral hemorrhage is a more desirable approach [7]. However, it should be applied flexibly in clinical work and should not overemphasize minimally invasive, and the incision and bone window should be enlarged to facilitate decompression and save lives in patients with large preoperative hematoma volume, brain herniation formation as well as intraoperative brain tissue collapse that is not obvious, heavy edema and poor brain pulsation. One study [9] showed that the efficacy of the craniotomy group for heavy cerebral hemorrhage was superior to that of stereotactic urokinase lysis because the hematoma must be removed as soon as possible in such patients who have developed brain herniation, and it is difficult to completely remove the hematoma in a timely manner at this stage by stereotactic aspiration alone. It is worth noting that surgery is only one part of the process of treating hypertensive cerebral hemorrhage, so in addition to paying attention to the brain before and after surgery, the functions of other organs of the body should also be paid attention to and adjusted to prevent and control various complications in order to achieve better results. Ultra-early surgery for hypertensive cerebral hemorrhage can improve the survival rate and recovery rate of patients with hypertensive cerebral hemorrhage by adopting different surgical methods according to the patients’ own conditions.