Secondary spontaneous intracerebral hemorrhages due to specific vascular malformations are discussed in this chapters. SICH includes all intraparenchymal hemorrhages other than those due to trauma and aneurismal bleed. Primary SICH (due to hypertension) account for approximately 70–80% of cases and are due to cerebral amyloid angiopathy (CAA), which affects the arterioles of the cortex only (not found in the white matter, basal ganglia, brainstem or cerebellum). Vascular anomalies (cavernomas, AVMs, venous angioma and capillary telangiectosis) are the second most common cause of SICH overall. Heavy drinkers, those with an irregularly shaped hematoma, poor GCS score, and a low level of fibrinogen are factors for hematoma progression. Smaller hematomas who are alert, stable, or improving should be treated medically. There is no evidence of an overall benefit of early surgery when compared to initial conservative treatment in supratentorial SICHs. However, it is widely recommended that easily accessible supratentorial (lobar) hematomas with mass effect, especially in the young and in those with a GCS score greater than 5 must be evacuated. Patients with larger hematomas who show progressive neurological deficit with intracranial hypertension be treated with evacuation and decompression. Patients with cerebellar hemorrhages greater than 3 cm or in whom brainstem compression and hydrocephalus are present, should undergo evacuation of the clot.