Although our clinical understanding remains our most important diagnostic tool, acute stroke therapy without neuroimaging is impossible. In most patients, only noncontrast computed tomography is used for diagnosis of acute stroke. However, findings based exclusively on clinical assessment and nonhemorrhagic computed tomography scans may no longer be appropriate for acute stroke treatment. From a pathophysiologic point of view, advanced computed tomography techniques and stroke magnetic resonance imaging provide much more information about the acute stroke patient as the basis of decision making in acute stroke treatment. Advanced computed tomography may provide information comparable with stroke magnetic resonance imaging, although a more detailed evaluation concerning these methods in clinical practice is required. This review gives the reader an integrated view on the current status of acute stroke imaging based on advanced computed tomography and multiparametric stroke magnetic resonance imaging protocols. These new imaging techniques allow for a far more individualized method of decision making according to the findings in each patient. This results in improved identification of patients with acute stroke syndromes, improved patient selection of those patients who are regarded suitable for thrombolysis, an extension of the rather strictly defined therapeutic time window for treatment, as well as a more sophisticated method of introduction of alternative therapies into clinical practice.