More than 20% of patients will experience a decrease in the Glasgow Coma Scale (GCS) of 2 or more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the emergency department (ED).6 Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital The risk for early neurological deterioration and the high rate of poor long-term outcomes underscore the need for aggressive early management. Prehospital Management Prehospital management for ICH is similar to that for ischemic stroke, as detailed in the recent American Heart Association Guidelines for the Early Management of Patients With Acute The primary objective is to provide airway management if needed, provide cardiovascular support, and transport the patient to the closest facility prepared to care for patients with acute stroke.10 Secondary priorities for EMS pro- viders include obtaining a focused history regarding the tim- ing of symptom onset (or the time the patient was last normal); information about medical history, medication, and drug use; and contact information for family. EMS providers should provide advance notice to the ED of the impending arrival of a potential stroke patient so that critical pathways can be initiated and consulting services alerted. Advance notice by EMS has been demonstrated to significantly shorten time to computed tomography (CT) scanning in the ED.11 Two studies have shown that prehospital CT scanning with an appropri- ately equipped ambulance is feasible and may allow for tri- age to an appropriate hospital and initiation of ICH-specific ED Management Every ED should be prepared to treat patients with ICH or have a plan for rapid transfer to a tertiary care center. The crucial resources necessary to manage patients with ICH include neurology, neuroradiology, neurosurgery, and critical Table 2. 