Objective: To compare and analyze the clinical effects of neuroendoscopic hematoma evacuation (ES) and minimally invasive drilling and drainage (MIDD) in the treatment of spontaneous intracerebral hemorrhage, as well as their impacts on neurological function and serological indicators. Methods: A retrospective analysis was conducted on 77 patients with intracerebral hemorrhage admitted to Gaoyou People’s Hospital and Northern Jiangsu People’s Hospital from January 2020 to December 2024. These patients were grouped according to their treatment methods, with 36 receiving MIDD (control group) and 41 receiving ES (experimental group). Perioperative indicators, neurological function before surgery and at 1 and 3 months postoperatively, and the incidence of complications during hospitalization and follow-up were compared between the two groups. Results: The experimental group had a longer operative time, greater intraoperative blood loss, a higher hematoma evacuation rate, and a shorter drainage tube placement time compared to the control group (P < 0.05). Compared to preoperative values, the Glasgow Coma Scale (GCS) scores of both groups continued to increase at 1 to 3 months postoperatively, with the experimental group showing higher scores; the National Institutes of Health Stroke Scale (NIHSS) scores of both groups continued to decrease, with the experimental group showing lower scores (P < 0.05). During hospitalization and follow-up, the overall incidence of complications was lower in the experimental group compared to the control group, but the difference was not statistically significant (P > 0.05). Conclusion: Endoscopic surgery (ES) for spontaneous intracerebral hemorrhage (ICH) can more thoroughly evacuate hematomas, improve neurological function, and shorten postoperative recovery time. Although it has drawbacks such as prolonged operative time and increased blood loss, its overall safety remains acceptable.