Spontaneous intracerebral hemorrhage (ICH) is a serious neurological condition in which early hematoma expansion occurs in approximately 38% of cases. Prehospital intensive blood pressure treatment reduces systolic pressure to less than 140 mmHg within two hours of onset, thereby limiting hematoma growth and may improve functional outcomes. The INTERACT-4 study showed the risks of misdiagnosed ischemic stroke, so accurate prehospital subtyping is needed. The RIGHT-2 and MR ASAP trials did not demonstrate a benefit for glyceryl trinitrate (GTN) and suggested potential harm. Mobile stroke units enable faster treatment, but face cost and scalability hurdles. Controversy persists about optimal blood pressure targets, timing, and patient selection. Future directions include the development of “Code ICH” pathways, individualized blood pressure targets, and validation of precision medicine approaches.