To review the pathophysiologic basis for intensive care management of patients with intracerebral hematoma and to present management strategies based on that analysis. Review of English language scientific and clinical literature using BRS Colleague search. Pertinent literature was selected to demonstrate physiologic principles, the clinical presentation, and the natural history of intracerebral hematoma. All clinical treatment trials were reviewed. Literature was reviewed to summarize physiologic principles and the results of clinical trials. The suggested medical management is based on the results of clinical trials and the applications of pathophysiologic principles. Spontaneous intracerebral hematomas acutely increase intracranial volume and reduce intracranial compliance, thus potentially increasing intracranial pressure and reducing cerebral perfusion. Therefore, any physiologic perturbation that could increase cerebral blood volume (hypercarbia, hypoxia, vasodilation) or reduce cerebral perfusion (hypotension) should be avoided. Acute hypertension may be a response to increased intracranial pressure and should be treated conservatively. Treatment of increased intracranial pressure is accomplished initially with hyperventilation, but this approach should be replaced rapidly with cerebrospinal fluid drainage alone or in combination with osmotic therapy employing diuretics, osmotic agents, or hypertonic saline to produce a state of hyperosmolality and euvolemia. Although the role of surgery remains controversial, it may be helpful in selected patients. Careful attention to pulmonary and metabolic status and to the consequences of therapy is required. Outcome is primarily determined by hemorrhage size, location, and initial level of consciousness. Stereotaxic aspiration of hematomas is a promising new therapy. The primary injury from intracerebral hemorrhage is exacerbated by disturbed intracranial physiology. Management should include principles that improve intracranial compliance and reduce intracranial pressure.