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This chapter discusses the diagnosis, evaluation and management of ischemic strokes. Patients with ischemic strokes may present with altered mental status or airway compromise requiring immediate treatment. If the patient is not protecting his/her airway due to neurological deficits or level of consciousness, intubation will be required. If possible, the neurological examination prior to intubation has to be assessed. Blood pressure monitoring is essential for maintaining brain perfusion and decreasing the risk of conversion to hemorrhagic stroke. The most likely cause of sudden decompensation is intracranial hemorrhage during tissue plasminogen activator (tPA) administration or increased intracranial pressure due to cerebral edema. The goal should be to maintain normocarbia while minimizing positive endexpiratory pressure (PEEP). Increased PEEP can lower venous return to the heart, leading to reduced cardiac output and worsening cerebral perfusion. Consultant neurosurgery can be pivotal during cerebellar infarcts or massive hemispheric infarcts.