There are two major types of surgical approaches for hypertensive cerebral hemorrhage: open cranial hematoma removal and drilled cranial hematoma puncture and drainage. The former emphasizes rapid removal of the hematoma and rapid reduction of intracranial pressure, while the latter involves gradual removal of the hematoma and gentle reduction of intracranial pressure. Craniotomy requires the surgeon to deal with the hematoma under direct vision. Exposure of the hematoma includes bone flap craniotomy, small bone window craniotomy, and hematoma removal is observed during surgery by the naked eye, operating microscope, or neuroendoscopy. The advantage of craniotomy is that the hematoma is cleared quickly and the bleeding vessels can be stopped by electrocoagulation; the disadvantage is that it is more traumatic and there is a possibility of increased brain injury during hemostasis, with a subsequent increase in postoperative complications. Therefore, the accuracy of cannulation is the key to the whole operation. Each unit can adopt stereotactic guidance for hematoma puncture, neuronavigation-assisted hematoma puncture, CT real-time monitoring for hematoma puncture and freehand hematoma puncture according to CT film positioning according to their own conditions. The advantages of puncture are less surgical trauma, fewer postoperative complications, shorter hospital stay and less treatment cost; the disadvantage is that if intraoperative bleeding cannot be stopped, further craniotomy is required to stop the bleeding. Since there are so many surgical methods, which one is more beneficial to the patient? This question cannot be generalized. As far as the doctor is concerned, the method he or she is best at is the best method, and doctors who are good at craniotomy to remove hematoma are not good at puncture. For patients, if they are of advanced age or have other serious medical diseases such as heart disease or liver or kidney insufficiency, puncture is preferred; for patients with both craniotomy and puncture, such as those with medium-sized hematomas and no brain herniation, puncture is preferred over craniotomy in terms of patient prognosis and medical costs. However, for patients with large hematomas and brain herniation, although we have successfully treated several patients with puncture and drainage, craniotomy is still the mainstay of surgery.