To the present day, the first and most widespread diagnostic approach in the assessment of acute stroke remains CT scan. Its sensitivity is very high (nearly 100%) in detecting intracerebral hemorrhage in the acute period, but its capability of revealing ischemic injury in the very first hours from symptom onset is relatively poor. Since the efficacy of thrombolytic treatment in acute stroke has been suggested by the ECASS and NINDS rt-PA trials, functional neuroimaging able to distinguish potentially salvageable tissue from irreversibly injured areas has acquired primary importance. The possibility to correctly identify the tissue of the ischemic penumbra within the first hours from symptom onset is essential for correct patient selection for thrombolitic treatment. Different imaging strategies are available for the definition of perfusion deficits within the acute time window; among these are positron emission tomography (PET), single photon emission computed tomography (SPECT), Xenon CT (XeCT), dynamic CT perfusion imaging (CTP), diffusion weighted magnetic resonance imaging (DW-MRI), and perfusion weighted magnetic resonance imaging (PW-MRI). Though each technique has its advantages and limitations to present day functional MRI remains the most widespread imaging technique in the assessment of acute stroke being more accessible than both SPECT and PET, and capable of giving information on both perfusion and tissue functional status in a single imaging session. In this paper we discuss the role of functional neuroimaging in acute stroke.