Objective: To compare the clinical effects of small bone window craniotomy for hematoma evacuation and borehole hematoma aspiration and drainage in the treatment of hypertensive intracerebral hemorrhage. Methods: The clinical data of 46 patients with hypertensive intracerebral hemorrhage who underwent craniotomy and hematoma evacuation via small bone window in our hospital from January 2022 to December 2024 were retrospectively collected and included in Group A. The clinical data of 43 patients with hypertensive intracerebral hemorrhage treated by borehole hematoma aspiration and drainage during the same period were selected and included in Group B. The surgical conditions, postoperative complications and neurological functions [National Institute of Health stroke scale, USA] NIHSS score and activities of daily living [Barthel Index (Barthel Index, BI)] of the two groups were statistically compared. Result: Compared with group A, the operation time of group B was significantly shortened, the intraoperative blood loss was significantly reduced, and the hematoma clearance rate at 72 was significantly increased (P < 0.05). The incidence of postoperative complications in group B was significantly lower than that in group A (P < 0.05). One month after the operation, the NIHSS scores of both groups decreased significantly compared with those before the operation, and the NIHSS score of group B was significantly lower than that of group A (P < 0.05). Three months after the operation, the BI scores of both groups were significantly improved compared with those before the operation (P < 0.05), but there was no significant difference in the BI scores between the two groups (P > 0.05). Conclusion: Compared with small bone window craniotomy for hematoma evacuation in the treatment of hypertensive intracerebral hemorrhage, the overall effect of borehole hematoma aspiration and drainage is better. It can not only shorten the operation time, reduce intraoperative blood loss and postoperative complications, but also remove the hematoma more thoroughly, which is conducive to the recovery of postoperative neurological function.