Objective To investigate the effect and security of neural endoscopic combined therapy with microscopic craniotomy hematoma removal in primary cerebral hemorrhage (PPH) patients. Methods From January 2016 to August 2023, 66 patients with PPH in our hospital were included. The study group (26 cases) was treated with neuroendoscopy-assisted micro-neurosurgery, while the control group (40 cases) was treated with simple microscopic craniotomy for removal of hematoma. Postoperative hematoma clearance rates, incidence of postoperative complications, postoperative mortality, postoperative 1 week Glasgow coma scale (GCS score) and 6 months after Glasgow outcome score (GOS score) of the two groups were evaluated. Results The hematoma clearance rate (93.5±5.4% vs. 85.8±8.7%), GCS score (9.3±1.2 vs.8.2 ±1.5) and GOS score (3.3±1.3 vs.2.6 ±1.3) in the study group were significantly higher than those in the control group (P < 0.05). The postoperative rebleeding rate (7.7% vs. 22.5%) and mortality rate (15.4% vs. 27.5%) in the study group were lower than those in the control group, but the differences were not statistically significant (P > 0.05). Conclusion The application of neuroendoscope may be helpful to improve the hematoma clearance rate and reduce postoperative bleeding risks, reduce intraoperative neurologic damage, and thus improve the prognosis of patients with PPH.