Background -To observe the therapeutic effect of con- ventional decompressive craniectomy with hematoma evacuation and frame-based stereotactic minimally inva- sive surgery (MIS) for supratentorial intracranial hema- toma with herniation. Methods -One hundred forty-nine patients with hyper- tensive ICH complicated with tentorial herniation were reviewed and analyzed in the present study. The intra- cranial hematoma was evacuated by emergency surgery within 6 h after admission. According to the authorized representatives' wishes and consent, 74 of the 149 patients were treated by conventional decompressive crani- ectomy followed by hematoma removal, defined as the CDC group, and the remaining 75 patients underwent frame- based stereotactic MIS for ICH evacuation, defined as the MIS group. The intervals between the admission to surgery, the duration of surgery, the amount of iatrogenic bleeding, the occurrence of postoperative rebleeding, and the recovery of neurological functions were compared between the two groups. All patients were followed up for 3 months. Secondary epilepsy, survival in a vegetative state, severe pulmonary complications, mortality, and activities of daily living (ADL) classification were also recorded and compared. Results -The interval between admission and surgery, the duration of surgery, and intraoperative blood loss in the MIS group were significantly decreased compared to the CDC group. The mortality rate, the rate of rebleeding, prevalence of vegetative state, and severe pulmonary com- plications in the MIS group were remarkably decreased compared to the CDC group. In the MIS group, the survivors' (ADL) grade also showed advantages. Conclusions -In the surgical treatment of hypertensive ICH complicated with tentorial herniation, frame-based stereotactic MIS for ICH showed advantages compared to conventional open surgery.