As of late 2009, 26 randomized controlled clinical trials of a thrombolytic agent versus control in acute ischemic stroke have been completed on 7152 patients. Most of these trials tested intravenous thrombolysis up to 6 hours after symptom onset. Of the trials, 55% tested recombinant tissue plasminogen activator, while others studied urokinase, streptokinase, recombinant pro-urokinase, ancrod, or desmoteplase. Overall, the odds of symptomatic intracranial hemorrhage were increased 3-fold (odds ratio 3.49, 95% confidence interval 2.81 to 4.33) in patients who received thrombolysis. In spite of this, there was a significantly reduced chance of poor outcome (combined death and dependency) during follow-up in patients who received thrombolytic therapy. This review summarizes current knowledge on the incidence, risk factors, clinical presentation, and management of intracerebral hemorrhage resulting from thrombolytic therapy. Dr. James S. McKinney is Medical Director of the Robert Wood Johnson University Hospital Comprehensive Stroke Center and Assistant Professor of Neurology at the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey. Dr. Steven R. Messé is Director of the Vascular Neurology Fellowship and Assistant Professor of Neurology at the University of Pennsylvania.