Objective: To explore the effects of two hematoma evacuation trajectories (outside-in dissection and inside-out dissection) on postoperative neurological recovery and the severity of cerebral edema in patients with spontaneous intracerebral hemorrhage (SICH). Methods: A total of 60 patients with SICH confirmed by cranial CT were enrolled and according to the surgical approach, patients were assigned to an outside-in dissection group (n=35) and an inside-out dissection group (n=25). In the outside-in dissection group, the hematoma cavity was exposed along the cerebral sulcus from outside to inside to identify the cavity boundary, followed by hematoma evacuation. In the inside-out dissection group, evacuation was performed via a central approach through the hematoma cavity, with stepwise dissection and removal from inside to outside. Neurological function [Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS)] on postoperative day 7 and day 30, the severity of cerebral edema on postoperative day 7, prognosis [Glasgow Outcome Scale (GOS)] on postoperative day 30, and postoperative complications were compared between the two groups. Results: On postoperative day 7 and day 30, the outside-in dissection group had higher GCS scores and lower NIHSS scores than the inside-out dissection group (P<0.05). The incidence of severe cerebral edema was lower in the outside-in dissection group than in the inside-out dissection group (P<0.05). On postoperative day 30, the outside-in dissection group achieved a higher GOS score (P<0.05). No significant difference was observed in the overall incidence of complications between the two groups (P>0.05). Conclusion: For patients with SICH, the outside-in dissection trajectory is more effective in promoting postoperative neurological recovery, reducing cerebral edema, and improving prognosis, with a favorable safety profile, and is therefore worthy of broader clinical application.