Early stroke management, and early initiation of secondary stroke prevention, may improve outcomes in patients with acute ischemic stroke. However, <10% of patients with acute ischemic stroke arrive at the receiving hospital within 3 hours of symptom onset. Factors such as poor public awareness of symptoms, lack of rapid detection by emergency medical services (EMS), poor coordination between EMS and the hospital emergency department, or delay of diagnosis on arrival at the emergency department are all contributing factors in the failure to provide prompt diagnosis and treatment of acute ischemic stroke. This article focuses on the critical steps in diagnosing ischemic stroke, starting at the initial patient evaluation by emergency personnel. Stroke mimics and different imaging techniques that may be used in the differential diagnosis and evaluation of acute ischemic stroke are also discussed.