This study was designed to compare the approaches and efficacies of two different ways of neurosurgical management for spontaneous putaminal hemorrhage (SPH): computed tomographic-guided aspiration (CTGA) and the key-hole approach (KHA). The indications of the two approaches are also explored. From September 2001 to 2003, a total of 1077 cases of SPH distributed in 135 hospitals all over the mainland of China were included for analysis. All cases had three-month follow-up data. The study was designed in a single-blinded manner to compare the efficacies of the different approaches. There were 563 cases in the CTGA group, 165 in the KHA group, and 217 cases in the conventional open craniotomy (COC) group. In the CTGA and KHA groups, the mortalities at one month after operation (M1m) were 17.9% and 18.3%, respectively, while the mortalities at three months after operation (M3m) were 19.4% and 19.4%, respectively (P >0.05). The postoperative complications due to CTGA (23.7%) were not significantly different from those due to KHA (25.7%) (P = 0.420). The M3m of patients with Glasgow coma scale (GCS) ≤8 was 3.45 and 4.0 times as much as those with GCS>8, respectively. The M3m of patients with complications was 3.92 times as much as those without complications. The M3m of patients with hemorrhage volume ≥70 mL was 2.67 times as much as those <70 mL. The CTGA is not better than KHA in the treatment of SPH in terms of a more favorable outcome or less mortality and morbidity, but CTGA could be the first choice for those with bleeding volumes ≤50mL, while KHA is the first choice for those with bleeding volumes >50 mL. © Higher Education Press and Springer-Verlag 2007.