Prior to 1995 no proven therapy existed for acute ischemic stroke. In 1996 the U.S. Food and Drug Administration approved the use of intravenous rt-PA in acute stroke based largely on the results of a two-part trial sponsored by the National Institutes of Health and National Institute of Neurological Disorders and Stroke (NIH/NINDS). Five years following approval, however, thrombolytic treatment remains underutilized, occurring in only 1 to 2% of all stroke patients. The medical community is now being called upon to organize systems capable of delivering acute stroke care in a time-urgent manner not previously contemplated. Critical care specialists may be called upon to treat stroke occurring in hospitalized patients or to continue care initiated in the emergency department. This article briefly reviews the pathogenesis of cellular injury in stroke and its initial evaluation and care and then focuses on the data involving thrombolytic reperfusion. Special attention is given to postthrombolytic critical care issues as these represent an important determinant in patient outcome. Secondary stroke prevention strategies and complication management are discussed along with general intensive care issues for the stroke patient.