An acute ischaemic stroke (AIS) is a non-specific state of brain injury with neuronal dysfunction, which has several pathophysiologic causes and is time critical. More than 70% of cases are due to thrombotic or embolic causes with resultant focal ischaemia and an accompanying neurological deficit. Initial assessment, stabilization and early imaging are important aspects of effective stroke management. Over the last two decades thrombolysis and mechanical thrombectomy have proven beneficial in reversing neurological deficits and improving functional outcomes. Guidelines now support administration of recombinant tissue plasminogen activator (rt-PA) up to 4.5 hours and extension of thrombectomy windows up to 24 hours after onset of symptoms in a select group of patients. Other important aspects of management include administration of antiplatelet agents (aspirin) within 48 hours, management within a specialist stroke unit, and decompressive hemi-craniectomy for malignant middle cerebral artery (MCA) stroke.