Acute ischemic stroke is discussed in this chapter. Prevention with attention to modifiable risk factors and patient education continue to be most important in stroke care. Major risk factors identified in India are history of TIA, hypertension, tobacco chewing and diabetes mellitus. There is a predominance of intracranial cause in India; extracranial location of the large artery atherosclerosis is the most common cause in the west. In addition to supportive treatment, Intravenous rTPA (0.9 mg/kg, maximum 90 mg) with 10% of the dose given as a bolus followed by an infusion lasting 60 minutes is the recommended treatment within 3 hours of onset of ischemic stroke. Associated edema is a life-threatening problem. Timely decompressive craniectomy is warranted in highly selected patients as a salvage procedure. The role of revascularization in acute stroke is being increasingly accepted. Newer therapies are under evaluation.