Stroke defines an acute vascular event in the brain and is a leading cause of death and disability. Ischemic stroke results from decreased blood flow to a portion of the brain with consequent cell death. Hemorrhagic stroke, on the other hand, is a result of bleeding into the brain. Ischemic stroke is far more common and is potentially treatable with thrombolytic therapy. While effective, the wide application of this therapy has been hampered by restrictive selection criteria based on time since onset of symptoms. Successful treatment requires a system capable of rapidly identifying and evaluating prospective candidates. In this context, use of community education, specific ED protocols and designated treatment centers may demonstrate some advantages. Evidence is emerging that patient selection by time since stroke onset, imaging characteristics, and intra-arterial treatment may increase the probability of recanalisation of occluded vessels. Normalization of serum glucose, acute blood pressure management and surgical extraction of intracerebral clot may be of benefit in some circumstances. The purpose of this report is to systematically review the available literature in the field of acute stroke evaluation and treatment. The following three areas were addressed: (1) What interventions in acute stroke (less than 24 hours from onset) are effective in reducing morbidity and mortality? (2) How do safety and effectiveness of these interventions vary by timing in relation to onset of symptoms? (3) What is the evidence that specific systems of care improve outcomes of acute stroke?