Acute stroke patients in the Molise region (Italy) are generally admitted to an Internal Medicine or Geriatrics hospital ward. In this study all 446 acute stroke admissions which occurred in Molise in 2004 were evaluated by analysing the following data: time from symptom onset to admission, diagnosis, acute care treatment, comorbidities, disease severity, complications, disability level, mortality, discharge modality and adherence to current guidelines. Mortality was very low in the study population (approximately 8% vs. 15-17% for the rest of Italy) and was found to be related to age above 80 years, disease severity, presence of dysphagia and to being admitted to the hospital of Campobasso (a sub-analysis of this population showed an equal degree of risk in the Geriatrics and Internal Medicine Units). Forty-two percent of survivors had a moderately severe to severe level of disability (Rankin score 4-5) and went home immediately after discharge (with a major part of the burden of care resting on families). At all study hospitals, computed tomography scan was performed within 48 hours of symptom onset, as per current guidelines for the management of acute stroke. On the other hand, adherence to current guidelines regarding other components of management such as evaluation for dysphagia, placement of a urinary catheter, aspirin therapy, rehabilitation, and performance of diagnostic procedures (e.g. doppler, echocardiogram) was not uniform in all study hospitals. Several aspects of stroke management should certainly be improved, in accordance with current international guidelines, in order to provide optimal acute stroke care in the Molise region. These include: time to hospital admission (e.g. by improving the emergency service "118"), standard treatment and diagnostic procedures, physical rehabilitation services and involvement of family physicians.