Background and Purpose: Spontaneous intracerebral hemorrhage (SICH) bears a poor prognosis, with a 30-day mortality rate of 35%–52%. The mass effects of hematoma and surrounding edema in larger supratentorial SICH lead to an increased intracranial pressure (ICP) and subsequent brain herniation. Multiple trials have failed to prove the superiority of surgical evacuation over conservative methods. However, surgery in a carefully selected set of patients is beneficial in reducing mortality and limiting disability. The aim of this study was to investigate the effectiveness of decompressive hemicraniectomy (DHC) with hematoma evacuation for treating patients with larger supratentorial SICH. Methods: This was a retrospective study conducted at our hospital between December 2016 and April 2020. A total of 55 patients with large supratentorial SICH treated with DHC and hematoma evacuation during this period. Patient characteristics and clinical information were analyzed, including age, sex, Glasgow Coma Scale (GCS), stroke severity (e.g. National Institutes of Health Stroke Scale), computed tomography (CT) scan data (signs of herniation, side and size of hematoma, midline shift), the time interval between ictus and surgery, surgical characteristics, and time of ventilation. Outcome was assessed by modified Rankin Scale (mRS) at six months after surgery. Results: Fifty-five patients (82% males) were treated with DHC. The mean age was 55 years. The median NIHSS (National Institutes of Health Stroke Scale) score at admission was 26 (range 9–32). Approximately two-thirds of the patients (69.1%) had hematoma located within the basal ganglia, while 30.9% had lobar hematomas. The median midline shift was 10.9 mm (range 4–20 mm). Intraventricular extensions were observed in 23 patients on the pre-operative CT scan. At discharge, the median mRS score was 5 (range 4–6), and 5 patients (9.1%) died. Six months after surgery, 17 patients (31%) had favorable outcomes (mRS scores 0–3), while the remaining patients had poor outcomes (mRS scores 4–6). The mortality rate was 25.5% (n = 14 patients). In comparison to the poor outcome group, those with favorable outcomes had a significantly higher GCS score (mean, 9.5 [SD = 2.5] vs 8.0 [SD = 1.9]; p = 0.013). Conversely, those who had poor outcomes were more likely to be older (mean 57.2 [SD = 10.4] vs 49.7 [SD = 10.7]; p = 0.017) and had a larger hematoma volume (mean 95.8 [SD = 32] vs 71.6 [SD = 33.0]; p = 0.018). Conclusions: Decompressive hemicraniectomy with hematoma evacuation could be beneficial for a selected group of young patients with large SICH.