Patients with acute ischemic stroke can be treated by intravenous thrombolysis within 3 hours or by intraarterial thrombolysis within 6 hours of symptom onset. Thrombolysis leads to an absolute reduction of a long term disability of 11-15% in selected patients. Aspirin is the drug of choice in most patients with acute stroke, if thrombolysis is contraindicated. Heparin is only used in acute stroke patients with high risk of recurrence. The diagnosis and treatment of medical and neurological complications remain crucial in the management of acute stroke.