Objective To compare the clinical effects of small bone flap craniotomy and decompressive craniectomy in the treatment of hypertensive intracerebral hemorrhage in the basal ganglia and thalamus and to investigate prognostic factors.Methods A retrospective analysis was performed on the clinical data of 132 patients with hypertensive intracerebral hemorrhage in the basal ganglia and thalamus who underwent microsurgery. Age, hematoma volume, hematoma rupturing into the ventricles, shift of midline, operation timing, surgical approach, preoperative Glasgow Coma Scale (GCS) score, and GCS score 24 hours postoperatively were recorded. A 3-month follow-up was performed in surviving patients to evaluate their activities of daily living. Multivariate logistic regression analysis was performed to identify prognostic factors.Results The prognostic factors were hematoma volume, hematoma rupturing into the ventricles, shift of midline >10 mm, preoperative GCS score, and operation timing. However, age, GCS score 24 hours postoperatively, and surgical procedure were not associated with prognosis.Conclusions Both small bone flap craniotomy and decompressive craniectomy are effective surgical procedures for hypertensive intracerebral hemorrhage in the basal ganglia and thalamus. The prognostic factors include hematoma volume, hematoma rupturing into the ventricles, shift of midline, preoperative GCS score, and operation timing.