Intracerebral hemorrhage (ICH) is a devastating event, carrying a very high morbidity and mortality rate. Hypertension and age-related amyloid angiopathy are the strongest risk factors for ICH, but smoking, anticoagulation with warfarin, excessive alcohol intake and cocaine also increase risk. This, the fourth in a Missouri Medicine series on stroke summarizes the clinical and imaging aspects of making the diagnosis of ICH. Current medical and surgical therapies are discussed as well as predictors of outcome and recommendations for secondary prevention.