Objective To compare the effects of microscopic small bone window craniotomy hematoma removal and hard channel puncture hematoma drainage on the prognosis and family acceptance of elderly hypertensive intracerebral hemorrhage （HICH）. Methods A total of 100 elderly patients with HICH admitted from January 2021 to April 2024 were selected as research subjects, and randomly divided into a hard channel puncture group （hard channel puncture hematoma drainage） and a bone window craniotomy group （microscopic small bone window craniotomy hematoma removal）, with 50 cases in each group. The effects of the two groups and the acceptance of surgery of family were compared and analyzed. Results The operation time and hospital stay in the hard channel puncture group were significantly shorter than those in the bone window craniotomy group （P<0.05）, and the clearance rate of hematoma and Glasgow outcome scale （GOS） score were significantly higher （P<0.05）. The incidence of postoperative complications in the hard channel puncture group was significantly lower than that in the bone window craniotomy group （P<0.05）. The surgical acceptance of patients' family members of the hard channel puncture group was significantly higher than that of the bone window craniotomy group （P<0.05）. There were no significant differences in the scores of Glasgow coma scale （GCS）, activity of daily living （ADL）, and short form 36 （SF-36） between the two groups before surgery （P>0.05）. At postoperative 3 months, the scores of GCS, ADL, and SF-36 between the two groups were significantly improved （P<0.05）, and the scores in the hard channel puncture group were significantly better than those in the bone window craniotomy group （P<0.05）. Conclusion In consideration of the characteristics of the HICH patients group, hard channel puncture drainage is a good choice for the families of patients who are unwilling to undergo craniotomy due to its advantages of short hospital stay and small trauma, and can be promoted in specific populations.