In recent decades, the surgical treatment of intracerebral hemorrhage (ICH) has become a focus of scientific inquest. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new surgical techniques to facilitate improved clinical outcomes. Currently, the two most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Achieving these goals would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. Herein the authors review conventional and minimally invasive surgical approaches to spontaneous ICH, articulating the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. The authors propose that strategies using minimally invasive techniques including clot aspiration with stereotactic guidance may give better results with improved clinical outcomes compared with standard open surgical approaches.