Intracerebral hemorrhage (ICH) is the least treatable form of stroke, with a high mortality rate. Early hematoma growth occurs in 18% to 38% of patients scanned within 3 hours of onset, and hematoma volume is a key predictor of poor outcomes. Recombinant activated factor VII (rFVIIa) is a potent hemostatic agent approved for treating bleeding in hemophilia patients with inhibitors and has shown hemostatic effects in patients with normal coagulation. A phase IIB trial of rFVIIa in ICH patients showed a 50% relative reduction in hematoma growth with all tested doses (40, 80, and 160 μg/kg), leading to an average reduction of 5 mL in hematoma volume. rFVIIa was associated with a 38% relative reduction in mortality and improved functional outcomes, despite a 5% incidence of arterial thromboembolic events. A phase III trial (FAST trial) is ongoing to confirm these results. ICH is a deadly and difficult-to-treat condition, with high mortality rates. Current treatments are mainly supportive, focusing on managing symptoms and preventing complications. Despite advances in other stroke types, effective treatment for ICH remains limited. Early hematoma growth, occurring in the first few hours after ICH, is a critical factor in poor outcomes. Studies show that hematoma growth is more likely when CT scans are performed early. The only consistently identified predictor of early hematoma growth is the time from symptom onset to CT scan. Ultra-early hemostatic therapy, such as rFVIIa, represents a new therapeutic approach for ICH. rFVIIa binds to activated platelets, generating activated factor X and promoting hemostasis. It has shown effectiveness in patients with normal coagulation and in those with hemophilia. A phase 2B trial of rFVIIa in ICH patients showed significant reductions in hematoma growth and improved outcomes. The trial found that rFVIIa reduced hematoma growth by 3.3 to 5.8 mL and improved functional outcomes, with a 38% relative reduction in mortality. However, rFVIIa was associated with a 5% incidence of arterial thromboembolic events. rFVIIa may also be useful in coagulopathic ICH, particularly in patients on warfarin, where it can rapidly normalize INR levels. However, further research is needed to determine the optimal dose and safety profile for this population. The FAST trial is ongoing to confirm these findings.Intracerebral hemorrhage (ICH) is the least treatable form of stroke, with a high mortality rate. Early hematoma growth occurs in 18% to 38% of patients scanned within 3 hours of onset, and hematoma volume is a key predictor of poor outcomes. Recombinant activated factor VII (rFVIIa) is a potent hemostatic agent approved for treating bleeding in hemophilia patients with inhibitors and has shown hemostatic effects in patients with normal coagulation. A phase IIB trial of rFVIIa in ICH patients showed a 50% relative reduction in hematoma growth with all tested doses (40, 80, and 160 μg/kg), leading to an average reduction of 5 mL in hematoma volume. rFVIIa was associated with a 38% relative reduction in mortality and improved functional outcomes, despite a 5% incidence of arterial thromboembolic events. A phase III trial (FAST trial) is ongoing to confirm these results. ICH is a deadly and difficult-to-treat condition, with high mortality rates. Current treatments are mainly supportive, focusing on managing symptoms and preventing complications. Despite advances in other stroke types, effective treatment for ICH remains limited. Early hematoma growth, occurring in the first few hours after ICH, is a critical factor in poor outcomes. Studies show that hematoma growth is more likely when CT scans are performed early. The only consistently identified predictor of early hematoma growth is the time from symptom onset to CT scan. Ultra-early hemostatic therapy, such as rFVIIa, represents a new therapeutic approach for ICH. rFVIIa binds to activated platelets, generating activated factor X and promoting hemostasis. It has shown effectiveness in patients with normal coagulation and in those with hemophilia. A phase 2B trial of rFVIIa in ICH patients showed significant reductions in hematoma growth and improved outcomes. The trial found that rFVIIa reduced hematoma growth by 3.3 to 5.8 mL and improved functional outcomes, with a 38% relative reduction in mortality. However, rFVIIa was associated with a 5% incidence of arterial thromboembolic events. rFVIIa may also be useful in coagulopathic ICH, particularly in patients on warfarin, where it can rapidly normalize INR levels. However, further research is needed to determine the optimal dose and safety profile for this population. The FAST trial is ongoing to confirm these findings.