Objective:To investigate the difference in efficacy between transsylvian-transinsular approach and transcortical-transtemporal approach for hematoma evacuation in the treatment of severe basal ganglia intracerebral hemorrhage in young adults.Methods:Young adult patients with severe intracerebral hemorrhage in the basal ganglia region underwent craniotomy hematoma removal in Ankang Central Hospital from February 2012 to February 2021 were retrospectively enrolled. The Glasgow Outcome Scale score was used to evaluate the outcome at 6 months after onset. 4-5 were defined as good outcome and 1-3 were defined as poor outcome. Multivariate logistic regression analysis was used to determine the independent influencing factors of the poor outcomes. Results:A total of 51 patients were enrolled. Their median age was 41 (interquartile range 39-43) years, and 29 were men (56.8%). The median Glasgow Coma Scale score at admission was 6.0 (interquartile range 5.5-7.0), and the median baseline hematoma volume was 38.0 ml (34.5-47.5 ml). Twenty-one patients (41.2%) were in the transsylvian-transinsular approach group and 30 (58.8%) were in the transcortical-transtemporal approach group. There were no significant differences in demographics, vascular risk factors and baseline clinical data between the transsylvian-transinsular approach group and the transcortical-transtemporal approach group. Compared with the transcortical-transtemporal approach group, the amount of intraoperative bleeding and hematoma residue in the transsylvian-transinsular approach group were less, the proportion of patients requiring decompressive craniectomy was lower (33.3% vs. 63.3%; χ2=4.449, P=0.035), and the duration of dehydration medication and hospital stay were shorter (all P<0.05). However, there was no significant difference in the good outcome rate between the two groups (66.7% vs. 56.7%; χ2=0.518, P=0.472). Multivariate logistic regression analysis showed that lower scores of Glasgow Coma Scale at admission (odds ratio 0.128, 95% confidence interval 0.017-0.977; P=0.047) and longer hospital stay (odds ratio 1.402, 95% confidence interval 1.065-1.844; P=0.016) were independently associated with the poor outcomes. Conclusion:For young adult patients with severe basal ganglia intracerebral hemorrhage who underwent hematoma removal, although there was no significant difference between the outcomes of patients with transsylvian-transinsular approach and transcortical-transtemporal approach, the former had more advantages.