Purpose of Review <p>Acute stroke in pregnancy, though rare, poses a significant clinical challenge due to its potential for devastating maternal and fetal outcomes. This review aims to equip clinicians with a practical framework for rapid evaluation and evidence-informed intervention, acknowledging the delicate balance between maternal benefit and fetal well-being, but prioritizing the outcomes to the dyad as the key consideration. Additionally, acute stroke will be further categorized into ischemic and hemorrhagic subtypes, with review of their unique presentations, diagnostic pathways, and management in the context of pregnancy.</p> Recent Findings <p>Despite growing awareness, recent literature over the past five years indicates that there has been minimal evolution in the fundamental approaches to diagnosis and management of acute stroke in pregnancy. Recent literature supports the use of thrombolytic therapy (e.g., alteplase) and mechanical thrombectomy during pregnancy without compromising fetal safety when clinically indicated. Guidelines regarding blood pressure control in hypertensive patients with hemorrhagic stroke are also highlighted. Data from recent studies revealed comparable treatment rates and outcomes between pregnant and non-pregnant individuals. Studies have also explored the role of adverse pregnancy outcomes (APOs) in increasing long-term stroke risk. Diagnostic delays remain common due to symptom overlap with other pregnancy associated conditions.</p> Summary <p>Stroke during pregnancy carries substantial maternal and fetal morbidity and mortality. Timely recognition, adherence to evidence-based treatment protocols, and interdisciplinary coordination are critical to optimizing outcomes. While retrospective studies support the safety and efficacy of imaging, thrombolysis, and mechanical thrombectomy in pregnant patients, prospective clinical trials are needed to establish optimal treatment timing, dosing, and long-term maternal-fetal outcomes.</p>