The role of clinical evaluation in the diagnosis and treatment of acute ischemic stroke remains unclear in current guidelines. The manifestations of stroke are diverse, so that the approach to evaluation and treatment are not the same for each patient. In this article, we review the role of neurological examination in diagnosis and treatment of acute stroke. In particular, the important content includes identification of large vessel occlusions, posterior circulation stroke, intracranial artery stenosis and expansion of the therapeutic window time for patients who are late to hospital