The prompt and aggressive management of acute stroke has become the standard of care as public awareness and the available successful treatment options both increase. The intravenous administration of tissue plasminogen activator within an established treatment window has been determined through large well-designed studies. The endovascular strategies for acute stroke have evolved significantly over the past 5 years and have been prompted by the limits of the intravenous treatment, as well as by the desire to demonstrate improved recanalization rates and improved long-term outcomes. Among these interventional treatment options are the intra-arterial administration of tissue plasminogen activator and newer antiplatelet agents, mechanical thrombectomy with the MERCI device, and intracranial angioplasty and stenting. This article outlines the major studies that have defined the current field of acute stroke management and discusses the basic treatment paradigms that are commonly utilized today.