BACKGROUND Currently to an increasing extent aggressive therapeutic approaches in ischemic stroke are discussed. These approaches include intraarterial and systemic thrombolysis to reduce infarction size and also decompressive surgical measures to prevent from fatal consequences of elevated intracranial pressure. This report gives an overview over these strategies. Their specific values are discussed. METHODS In acute vertebrobasilar artery occlusion an attempt of intraarterial thrombolysis is indicated because of the mostly poor prognosis of large brainstem infarction. Acute artery occlusion in carotid territory has a better prognosis, so that the indication of intraarterial thrombolysis has to be regarded more critically. In view of recent reports systemic rt-PA-thrombolysis seems to be justified in well defined cases independently from site of occlusion. At present there is no longer doubt about the benefit of decompressive surgery in space occupying cerebellar stroke. The value of surgery in malignant brain infarction in carotid territory is not clear due to date. Further randomised studies are necessary to learn more about benefit, risks and required proceedings in space occupying supratentorial infarction. CONCLUSIONS A well defined group of patients suffering from ischemic stroke seems to benefit from aggressive therapeutic approaches in ischemic stroke. Concerning the selection of patients and management of those approaches a close cooperation with an experienced center is required.