Recent advances in the diagnosis and treatment of stroke have justified its management as a medical emergency. This article summarises current recommendations for the initial management of major types of stroke with emphasis on acute therapy for ischaemic stroke. Recommendations are based on results of well-designed clinical trials. An acute stroke care team and an acute stroke unit should be established in all regional hospitals. Diagnosis of stroke must be accurate. General management aims for prevention and treatment of neurological and systemic complications, whereas specific management varies according to the stroke type and the underlying pathogenic mechanisms. For selected patients with ischaemic stroke, intravenous recombinant tissue plasminogen activator or a modified viper venom within 3 hours of onset, or intra-arterial pro-urokinase within 6 hours may improve functional outcomes. Neurosurgical treatment is indicated for some patients with ischaemic or haemorrhagic strokes. Prevention of recurrence and rehabilitation are the core components of subsequent management.