Urgent evaluation of patients with acute ischemic stroke allows for a comprehensive assessment of management options. These include thrombolysis and thrombectomy, depending on symptom onset and severity, the presumed location of the occlusion, and patient comorbidities and potential for improvement. For patients who present within 4.5 hours of onset of disabling symptoms consistent with acute ischemic stroke and with no contraindications, intravenous thrombolysis is indicated. Acute mechanical thrombectomy may be indicated for patients who present within 24 hours of symptom onset and have symptoms consistent with a large vessel occlusion. After reperfusion therapy, patients require close neurologic monitoring. Patients who receive reperfusion therapy tend to have better functional outcomes than patients who do not. Secondary prevention includes use of antithrombotics and glycemic control. Common issues in the acute setting include cerebral edema, hemorrhagic transformation, and symptomatic carotid disease.