Ganglionic Intracerebral hemorrhage accounts for about 10-30% of strokes and represents 50% of spontaneous ICH. There is a big controversy about the management of such cases, whether medical or surgical. Surgical approaches are numerous.The current study was carried in the neurosurgery department in Kasr Al-Aini hospital on 30 patients where we have used the two most recent trends in management, the endoscopic evacuation and the transsylvian transinsular approach.In the study we have concluded that early evacuation before 24 hours is a must. The endoscopic tools available are not suitable to evacuate such hematomas, especially with late presentation. The transsylvian transinsular approach is a minimally invasive technique, familiar to almost all neurosurgeons. The emergency department staff and ICU staff need to be specially trained to deal with such cases.