BACKGROUND: Acute bilateral basal ganglia hemorrhage is a rare and life-threatening condition, often associated with high morbidity and mortality. Timely diagnosis and intervention are crucial to improving outcomes. This report presents a case successfully managed with minimally invasive surgery (MIS). CASE DESCRIPTION: A 44-year-old male, previously independent in daily activities with a medical history of hypertension, presented to the emergency department with severely altered consciousness [Glasgow Coma Scale (GCS) score 6]. Immediate intubation and admission to the intensive care unit (ICU) were initiated. Computed tomography (CT) angiography confirmed no evidence of vascular abnormalities or aneurysms. Tubular retractor-assisted microsurgical evacuation was performed to remove the hematoma and reduce intracranial pressure (ICP). The patient demonstrated neurological improvement, including spontaneous eye opening by postoperative day 3 and discharge from the ICU on day 10, highlighting the effectiveness of the intervention. He was subsequently discharged from the hospital on day 15 and transferred to a rehabilitation center for further recovery. Bilateral basal ganglia hemorrhage is rare, and its management often poses challenges due to high morbidity and mortality rates. CONCLUSIONS: This case underscores the importance of prompt diagnosis and intervention in bilateral basal ganglia hemorrhage. MIS offers a viable therapeutic option that may enhance recovery while reducing surgical risks.