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Intracerebral hemorrhage (ICH) carries the highest mortality and morbidity of all stroke types. Although small vessel disease accounts for the majority of ICH, there is a broad spectrum of other etiologies. Modern imaging techniques are a cornerstone of the work-up process. The goals of acute management are to prevent hematoma expansion, stabilize and prevent failure of vital functions, and establish the cause of ICH. ICH expansion can be alleviated by rapid correction of any contributing coagulopathy and antihypertensive treatment. Early prognostication within 24 hours after onset is imprecise. For this reason, international guidelines recommend postponing decision-making on withdrawal or limitation of care until at least the second full day of hospitalization. Indications for intensive care differ from those for neurosurgical treatment and should be assessed separately. Neurosurgical treatment is commonly recommended to reduce mortality in the presence of hydrocephalus or infratentorial hematomas with significant mass effect. In deteriorating patients with supratentorial ICH, surgical treatment can be considered as a life-saving treatment on an individual basis, with consideration given to anatomical location, level of consciousness and medical history.