Controversy still exists on surgical management of acute stroke. Even if surgical therapy represents often a life-saving measure, the issue of acceptable outcome remains open. Persuasive evidence for outcome benefit is limited. For large ischaemic strokes, recent convincing data suggest that decompressive surgery significantly reduces mortality and improves outcome quality. On the other hand, despite the long tradition in surgical removal of intracranial haematomas, the recent evidence has not been sufficient to resolve the basic argument whether to operate or not. Most recently, hopeful preliminary data have emerged on new approaches in the treatment of intraventricular haemorrhage. In this article, we review the current neurosurgical options in acute ischaemic and haemorrhagic stroke.