OBJECTIVE: To investigate the effects of early stepwise controlled decompression combined with mild hypothermia therapy (MHT) on clinical outcomes in patients with severe hypertensive intracerebral hemorrhage (sHICH). METHODS: A total of 80 sHICH patients were included, with 32 cases in the control group receiving conventional craniotomy for hematoma evacuation and MHT, and 48 cases in the observation group undergoing early stepwise controlled decompression plus MHT. The two groups were compared in terms of treatment efficacy, hematoma clearance rate, prognosis, National Institutes of Health Stroke Scale (NIHSS) and Functional Ambulation Category (FAC) scores, complications, cerebral edema volume, and serum biochemical indices. RESULTS: The observation group demonstrated significantly better efficacy, higher hematoma clearance rates, and improved clinical outcomes compared to the control group (all P<
0.05). Postoperatively, the observation group had significantly lower NIHSS scores, reduced levels of neuron-specific enolase, central nervous system-specific protein, and malondialdehyde, as well as lower incidences of encephalocele, cerebral infarction, and delayed intracranial hematoma (all P<
0.05). Additionally, cerebral edema volume was significantly reduced, while FAC scores were notably higher in the observation group (both P<
0.05). CONCLUSION: Early stepwise controlled decompression combined with MHT is highly effective in the treatment of sHICH, leading to better neurological recovery, reduced cerebral edema, and improved biochemical profiles.