Hematoma volume is a significant concern in basal ganglia hemorrhage, with no clear cutoff to guide the choice between conservative and surgical management, particularly for larger hematomas where the optimal approach remains controversial. This study aimed to determine the maximum hematoma volume suitable for conservative treatment and the volume that necessitates surgical intervention in patients with basal ganglia hemorrhage. A total of 387 cases of basal ganglia hemorrhage from 2019 to 2021 were analyzed, evaluating patient demographics, medical history, and initial CT brain scans to assess hematoma volume. Outcomes of medical and surgical treatments were compared using multivariate logistic and Cox regression analysis. For patients treated with medical management alone, mortality rates did not differ significantly between hematoma volumes of 10-39.9 mL and those under 10 mL. Receiver operating characteristic (ROC) curve analysis identified a cutoff volume of 45.3 mL, with a sensitivity of 80.82% and specificity of 91.67% for predicting survival. Kaplan-Meier survival analysis revealed a reduced mortality hazard ratio (0.17) with surgical intervention for hematomas exceeding 45.3 mL. However, surgical treatment for volumes under 30 mL was associated with higher mortality compared to medical management. Surgical intervention showed a clear survival benefit for hematoma volumes of at least 60 mL, while conservative treatment remained appropriate for volumes up to 45.3 mL. For volumes between 45.3 mL and 59.9 mL, the decision to operate should be guided by the surgeon's judgment and patient-specific factors such as comorbidities, brain atrophy. In conclusion, conservative management is effective for hematomas up to 45.3 mL, while surgical intervention is absolutely indicated for volumes of 60 mL or more. These findings provide valuable guidance for optimizing treatment strategies in basal ganglia hemorrhage.