The optimal management of acute cerebral infarction requires consideration of the diagnosis, aetiology, identification of problems, general and specific aspects of care, and prevention of further vascular events. Stroke is a clinical diagnosis but cranial computed tomography (CT) scanning is invaluable to exclude the possibility of cerebral haemorrhage or where the diagnosis is uncertain. Good general care under a specialist multidisciplinary team can reduce mortality and the need for institutional care. Despite promising results from experimental studies, no routine drug therapies have yet shown clinical benefit in acute stroke. Several large trials are currently evaluating anticoagulant, antiplatelet, thrombolytic and neuroprotective agents. Many other proposed therapies have been subject to limited evaluation. Aspirin has a proven role in the prevention of further vascular events after a stroke or transient ischaemic attack. Warfarin, and to a lesser extent aspirin, can prevent recurrent events in patients with nonrheumatic atrial fibrillation. Concerns remain about the safety of warfarin in routine geriatric medical practice. The risk of recurrent stroke in patients with a symptomatic severe carotid artery stenosis is greatly reduced by endarterectomy.