Three of the world's top 10 most populous countries are located in South Asia. The health-care problems of this region are different from those in the developed world, and the rapidly changing socioeconomic scenario, fast-increasing urbanization and longevity, changes in dietary patterns, and decrease in mortality from infectious diseases has made chronic illnesses of old age, such as coronary artery disease and stroke, an important area of focus. This article reviews stroke epidemiology and management issues in four South Asian countries: India, Pakistan, Sri Lanka and Bangladesh. The available literature is limited and mostly hospital-based, and differing study methodologies make direct comparisons difficult. The high prevalence of traditional risk factors, including hypertension, diabetes, dyslipidaemia and smoking, in these countries is alarming, and several nontraditional risk factors, such as water-pipe use, desi ghee, chewable tobacco, and infectious causes of stroke, are understudied. Access to tertiary stroke care is limited, and the use of tissue plasminogen activator is scarce. In addition, public and caregiver awareness of stroke risk factors and management is disappointing, and the interest of governments and policy makers in stroke is suboptimal. Interventions to reduce stroke burden and stroke-related mortality in South Asia should have a substantial impact at the global level.