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Currently, intracerebral hemorrhage (ICH) patients from neighbor islands are air transported to a higher-level facility on Oahu with neuroscience expertise. However, the majority of them do not receive subspecialized neurosurgical procedures (SNP) upon transfer. Hence, their transfer may potentially be considered as excess cost.Consecutive ICH patients hospitalized at a tertiary center on Oahu between 2006 and 2013 were studied. Subspecialized neurosurgical procedure was defined as any neurosurgical procedure or conventional cerebral angiogram. Total excess cost was estimated as the cost of interisland transfer multiplied by the number of interisland transfer patients who did not receive any SNP.Among a total of 825 patients, 100 patients (12%) were transferred from the neighbor islands. Among the neighbor-island patients, 69 patients (69%) did not receive SNP, which translates to $1 035 000 of excess cost over an 8-year period (approximately $129 375/y). Multivariable analyses showed age (odds ratio [OR], 0.95; 95% confidence interval [CI]: 0.94-0.96), lack of hypertension (OR, 1.62; 95% CI: 1.002-2.61), initial Glasgow Coma Scale (OR, 0.94; 95% CI: 0.89-0.98), lobar hemorrhage (OR, 2.74; 95% CI: 1.59-4.71), cerebellar hemorrhage (OR, 5.47; 95% CI: 2.78-10.76), primary intraventricular hemorrhage (OR, 4.40; 95% CI: 1.77-10.94), and any intraventricular hemorrhage (OR, 2.47l 95% CI: 1.53-3.97) to be independent predictors of receiving SNP.Approximately two-thirds of ICH patients who were air transferred did not receive SNP. Further study is needed to assess the cost-effectiveness of creating a triage algorithm to optimally select ICH patients who would benefit from air transport to a higher-level facility.