Objective To compare the efficacy of craniotomy and puncture drainage in the treatment of moderate (30-60 ml) hypertensive intracerebral hemorrhage (ICH) in the basal ganglia and to investigate the selection of reasonable surgical procedures.Methods A total of 166 patients with moderate hypertensive ICH in the basal ganglia were divided into two groups (positive group and negative group) according to the presence or absence of computed tomography angiography (CTA) "spot sign". Patients in each group were randomly divided into craniotomy subgroup and puncture drainage subgroup. The rebleeding rate, mortality, modified Rankin Scale (mRS) score, and Barthel Index (BI) of activity of daily living at 90 days after onset were compared between the two subgroups in the positive and negative groups.Results For the positive group, the puncture drainage subgroup had significantly higher rebleeding rate and mortality than the craniotomy subgroup (P<0.05); there were no significant differences in the proportion of dependent survival patients (mRS score >2) and the proportion of patients with good prognosis (BI ≥ 90) between the two subgroups (P>0.05). For the negative group, there were no significant differences in rebleeding rate, mortality, the proportion of dependent survival patients, and the proportion of patients with good prognosis between the two subgroups (P>0.05).Conclusions For patients with moderate (30-60 ml) hypertensive ICH in the basal ganglia, craniotomy is suitable for patients with CTA "spot sign" to reduce the rebleeding rate and mortality; puncture drainage is suitable for patients without CTA "spot sign" due to its advantages of simple operation and minimal invasion. There is no significant difference in the prognosis of patients between the two surgical procedures. So it is necessary to classify patients before surgery according to the presence or absence of CTA "spot sign".