Intracerebral haemorrhage (ICH) results from the spontaneous rupture of an intracranial vessel. It comprises about 15% of all cerebrovascular diseases, and carries the highest risk of mortality and morbidity. ICH volume is the strongest single predictor of a bad outcome. Recent evidence shows that haematoma expansion is associated with early neurological deterioration and it occurs in 38% of patients. Ultra-early haemostatic agents such as recombinant factor VII (rfVII) may have a role in ICH management; although further clinical trials are required for it to be used in routine management. This article reviews its pathophysiology and natural history, and the evidence supporting recent advances in medical and chirurgical management for spontaneous ICH.