To compare the prognosis of malignant versus benign thalamic hemorrhage, and to study the imaging features of malignant thalamic hemorrhage and its predictive value for short-term prognosis. Meth? ods: A total of 196 patients with spontaneous thalamic hemorrhage were recruited, including 159 patients with malignant thalamic hemorrhage and 37 with benign thalamic hemorrhage. The patients were followed up for 3 months, and prognosis was assessed using the modified Rankin Scale (mRS). The general clinical data and influencing factors of prognosis of both groups were compared, and the influencing factors of prognosis in patients with malignant thalamic hemorrhage were further analyzed. Results: Age, hematoma volume at admission, and malignant thalamic hemorrhage were independent predictors of poor prognosis after thalamic hemorrhage (all OR>1, P<0.05). Age, hematoma volume at admission, and degree of internal capsule compression (D value) were independent predictors of poor functional prognosis after malignant thalamic hemorrhage (all OR>1, P< 0.05). ROC curve analysis showed that the D value as a predictor had a sensitivity of 0.79, specificity of 0.68, and cut-off value of 2.1 cm. When the degree of internal capsule compression is greater than 2.1 cm, the prognosis in malignant thalamic hemorrhage patients may be poor. Conclusion: Malignant thalamic hemorrhage is an independent predictor of poor prognosis in thalamic hemorrhage patients. Age, hematoma volume at admission, and D value are independent predictors of poor prognosis in patients with malignant thalamic hemorrhage.