Objective To analyze the clinical effect of craniotomy versus burr-hole irrigation and drainage in the treatment of chronic subdural hematoma with acute hemorrhage.Methods A retrospective analysis was performed for the clinical and follow-up data of 47 cases of chronic subdural hematoma with acute hemorrhage admitted to Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, from May 2008 to August 2017. Twenty-three cases were treated with craniotomy to remove hematoma (craniotomy group); 24 cases were treated with burr-hole irrigation and drainage (drilling group). The postoperative indwelling catheter time, length of hospital stay, residual hematoma volume at 1 month after operation, and the number of recurrences at 3 months were compared between the two groups, and the clinical efficacy was analyzed.Results Three cases were lost to follow-up, consisting of 2 cases in the craniotomy group and 1 case in the drilling group. In the craniotomy group, the indwelling catheter time was 1.9±0.7 days, the length of hospital stay was 10.8±1.3 days, the residual hematoma volume was 2.0±0.5 ml at 1 month after operation, and no recurrence was found. In the drilling group, the indwelling catheter time was 5.5±0.9 days, the length of hospital stay was 11.2±1.2 days, the residual hematoma volume was 13.4±1.8 ml at 1 month after operation, and the number of recurrences was 3. There was no significant difference in the length of hospital stay between the two groups (P>0.05), while the indwelling catheter time, residual hematoma volume at 1 month after operation, and recurrence rate were significantly different between the two groups (P<0.05).Conclusions For patients with chronic subdural hematoma accompanied by acute hemorrhage, craniotomy for hematoma removal is superior to burr-hole irrigation and drainage with shorter indwelling catheter time, less residual hematoma volume at 1 month after operation, and lower recurrence rate.