A stroke occurs when brain tissue dies secondary to insufficient blood supply. Treatment for acute ischemic stroke requires rapid recognition of symptoms and prompt arrival at an emergency department prepared to deliver thrombolytic therapy or other advanced care. This chapter presents a set of key challenges and recommendations for the prehospital care of stroke. Recommendations for stroke recognition, the role of Emergency Medical Services (EMS) providers, treatment, and scene management are discussed. Management of strokes is a medical emergency, and prehospital care plays a large role in getting eligible patients the reperfusion treatment they need. Several prehospital interventions are required to avoid worsening of the ischemic injury or complications of the ischemia, including hypoglycemia, hypoxia and blood pressure extremes. The effects of hospital bypass in favor of stroke centers of care have been studied in the prehospital environment and appear promising.