Background and Objectives:Despite decades of increasingly sophisticated neurocritical care, patient outcomes after spontaneous intracerebral hemorrhage (ICH) remain dismal. Whether this reflects therapeutic nihilism, or the effects of the primary injury has been questioned. In this contemporary cohort, we determined the 30- and 90-day mortality, cause-specific mortality, functional outcome, and the effect of surgical intervention in a culture of aggressive medical and surgical support.Methods:This is a retrospective cohort study of consecutive adult patients with spontaneous ICH admitted to a tertiary neurocritical care unit. Patients with secondary ICH and those subject to limitation-of-care before 72-hours were excluded. For each ICH score, 30- and 90-day mortality, and the modified Rankin Scale (mRS) were examined. The effect of craniotomy/craniectomy ± hematoma evacuation on the outcome of supratentorial ICH was determined using propensity score matching. Median patient follow-up after discharge was 2.2 [IQR, 0.4-4.4] years.Results:Among 319 patients with spontaneous ICH (median age was 69 [IQR, 60-77] years, 60% male), 30- and 90-day mortality were 16% and 22%, respectively, and unfavorable functional outcome (mRS 4-6) was 50% at a median 3.1-months after ICH. Admission predictors of mortality mirrored those of the original ICH score. Unfavorable outcomes for ICH score 3 and 4 were 73% and 86%, respectively. The most common adjudicated primary causes of mortality were direct effect or progression of the ICH (54%), refractory cerebral edema (21%), and medical complications (11%). In matched analyses, lifesaving surgery for supratentorial ICH did not significantly alter mortality or unfavorable functional outcome in patients overall. In subgroup analyses restricted to (1) surgery with hematoma evacuation, and (2) ICH score 3 and 4 patients, the odds of 30-day mortality were reduced by 71% (OR, 0.29, 95% CI, 0.09-0.9, p=0.032) and 80% (OR, 0.2, 95% CI, 0.04-0.91, p=0.038), respectively, but no difference was observed for 90-day mortality or unfavorable functional outcome.Discussion:This study demonstrates that poor outcomes after ICH prevail despite aggressive treatment. Unfavorable outcomes appear related to direct effects of the primary injury and not to premature care limitations. Lifesaving surgery for supratentorial lesions delayed mortality but did not alter functional outcomes.