Spontaneous intracerebral hemorrhage (ICH) continues to be one of the most morbid and deadliest forms of stroke. Despite this, there is no conclusive surgical treatment with proven superiority over medical management for this disease. For infratentorial disease, management of hydrocephalus and posterior fossa decompression with or without hematoma evacuation is the accepted form of treatment. For supratentorial disease, the superior option between medical management and surgical hematoma evacuation and by extension the optimal technique for hematoma evacuation continues to be a matter of debate. Likely, some combination of aggressive medical management and proper application of minimally invasive surgical hematoma evacuation is necessary to optimize outcomes, but research is still ongoing to delineate the proper surgical technique and patient selection.