PURPOSE OF REVIEW: We review the current evidence for medical and surgical 
treatments of spontaneous intracerebral hemorrhage (ICH).
RECENT FINDINGS: Therapy with hemostatic agents (e.g. factor VIIa and tranexamic 
acid) if started early after bleeding onset may reduce hematoma expansion, but 
their clinical effectiveness has not been shown. Rapid anticoagulation reversal 
with prothrombin concentrates (PCC) plus vitamin K is the first choice in 
vitamin K antagonist-related ICH. In ICH related to dabigatran, anticoagulation 
can be rapidly reversed with idarucizumab. PCC are recommended for ICH related 
to FXa inhibitors, whereas specific reversal agents are not yet approved. While 
awaiting ongoing trials studying minimally invasive approaches or 
hemicraniectomy, the role of surgery in ICH remains to be defined. Therapies 
targeting downstream molecular cascades in order to prevent secondary neuronal 
damage are promising, but the complexity and multi-phased nature of ICH 
pathophysiology is challenging. Finally, in addition to blood pressure control, 
antithrombotic prevention after ICH has to consider the risk of recurrent 
bleeding as well as the risk of ischemic events. Treatment of acute ICH remains 
challenging, and many promising interventions for acute ICH await further 
evidence from trials.