Cerebrovascular disease encountered in the emergency department (ED) includes transient ischemic attacks (TIAs) and infarcts (strokes). The purpose of the initial evaluation is to determine whether there is evidence of a stroke, what part of the brain is affected, and whether the patient is a candidate for urgent intervention such as thrombolytic therapy. A chemistry profile, complete blood count (CBC) with platelets, and coagulation profile are essential after completion of brief examination. Attention to adequate airway protection, oxygenation, and circulatory function is essential for management of patients with acute stroke. The use of anticoagulants (heparin or low molecular heparins) remains the most controversial subject in the management of acute stroke. Patients with acute or hemorrhagic strokes need to be admitted to the hospital for further evaluation and management. A neurosurgeon should participate in the care of most patients with intracerebral hemorrhages (ICH) and all patients with subarachnoid hemorrhages (SAH).