To explore the surgical outcomes and prognosis of chronical subdural hematoma (CSDH) with acute hemorrhage at the initial presentation. Methods: A retrospective analysis was conducted on the clinical data of 166 patients with CSDH who underwent surgical treatment in a single center. Among them, 28 cases were diagnosed with acute-on-chronic subdural hematoma (acSDH), and the surgical outcomes and prognosis of this special type of CSDH were explored. Results: Acute chronic subdural hematomas (acSDH) accounted for 16.87% of all chronic subdural hematomas (CSDH) during the same period. Compared to CSDH without acute hemorrhage, patients with acSDH exhibited significantly higher postoperative complication rates (P<0.05). However, no statistically significant differences were observed between the two groups in terms of recurrence rate, total hospital stay duration, discharge modified Rankin scale (mRS) scores, or favorable surgical outcome rates (P>0.05). Although mortality rates at both 30 days and 1 year were numerically higher for acSDH cases, these differences did not reach statistical significance (P>0.05). Kaplan-Meier survival analysis revealed overlapping survival curves for both cohorts, with no significant intergroup difference in survival probability (P> 0.05). Conclusion: Patients initially diagnosed with acSDH experience higher postoperative complication rates compared to those without acute hemorrhage, yet exhibit similar recurrence rates. Surgical treatment for acSDH yields favorable outcomes.