Acute ischemic stroke therapy has two basic therapies, dissolving the intravascular occlusion by thrombolytic therapy and protecting the brain from the harmfull cellular, and metabolic consequences ofischemic injury by neuroprotective therapy. It seems most likely that the methods that will be used to treat the acute ischemic stroke patient will be multiple, likely a combination of thrombolytic therapy for early reperfusion and neuroprotective therapy for maintaining vitality. In the last decade, a number of advances in the field of imaging and pharmacology have been made which should provide meaningful improvement for the management of acute ischemic stroke patients in the near future. This update summarizes recent clinical trials and emphasizes the question of risk versus benefit for the acute ischemic stroke therapies being developed.