Ischemic stroke affects 2.5% of the population of the United States and is the leading cause of disability. This article outlines the evidence to support intravenous thrombolysis with alteplase and tenecteplase, thrombolysis in the setting of DWI/flair mismatch, endovascular treatment in the 6-hour and 6- to 24-hour window, and the use of telemedicine in acute stroke. Current controversies and ongoing trials within endovascular treatment are also detailed. Case presentations are included to provide clinical context and the application of data to practice.