Acute ischemic stroke now is being treated as a medical emergency. The success of the use of tissue plasminogen activator (t-PA) within 3 hours of onset of stroke serves as an impetus for an approach that emphasizes prompt recognition, rapid transportation to a medical center, speedy evaluation and urgent treatment. However, the safe and effective administration of t-PA requires the involvement of physicians who have expertise in the diagnosis and management of stroke, the timely availability of modern brain imaging studies and the facilities to handle complications of treatment. While t-PA improves outcomes, it is just a component of management that also includes measures to limit or prevent medical or neurologic complications, rehabilitation and institution of therapies to forestall recurrent stroke. In the future, additional therapies likely will be shown as effective in lessening the neurologic consequences of brain ischemia.