The choice of intervention for acute ischemic stroke is dependent on a number of variables. The patient must be seen and evaluated within a limited temporal window, and treatment decisions must be made rapidly. This review discusses methods being used to improve patient and staff recognition of stroke, as well as the initial diagnostic study of an acute stroke patient. It then reviews parameters that may influence outcome, such as blood pressure, serum glucose, supplementary oxygenation, and temperature. The potential benefits and risks of thrombolysis, anticoagulation, and revascularization are discussed. Finally, treatments for severe ischemic strokes with malignant cerebral edema are reviewed, along with new techniques, including hypothermia and hemicraniectomy. Curr Opin Crit Care 2000, 6:77–84 © 2000 Lippincott Williams & Wilkins, Inc.