Spontaneous intracerebral hemorrhage (ICH) is associated with the highest mortality of all cerebrovascular events, and most survivors never regain functional independence. Many clinicians believe that effective therapies are lacking for patients who have ICH; however, this perception is changing in light of new data on the pathophysiology and treatment of this disorder, in particular, research establishing the role of medical therapies to promote hematoma stabilization. This article discusses the basic principles of management of ICH, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. In addition, minimally invasive surgery to reduce clot size is discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.