To examine the current emergency referral and care for acute stroke at a Japanese tertiary emergency hospital with a 24-h stroke team and care unit, we surveyed the presentations of patients with acute ischemic stroke or transient ischemic attack (TIA) seen within 7 days of onset. Delay from symptom onset to arrival at our hospital, from arrival to initial diagnostic brain computed tomography (CT), and the type of anti-thrombotic treatments were evaluated. During the 18-month period, there were 254 ischemic events in 244 patients; 239 (94%) had an ischemic stroke and 15 (6%) TIA. Eighty-two (32%) events presented within 3 h of onset, and 102 (40%) and 179 (70%) within the first 6 and 24 h, respectively. The median delay from hospital arrival to CT was 32 min, ranging 10 min to 22 h. Two hundred (79%) events underwent CT within 1 h of arrival (n=172) or at the referral hospitals before transfer (n=28). Direct ambulance transportation and more severe neurological deficits were independent predictors both for early arrival and short in-hospital delay to CT. Anti-thrombotic therapies including anticoagulant and/or antiplatelet medications were given in 237 (93%) episodes. Two (1%) patients received thrombolysis, although 18 (7%) patients fulfilled the National Institute of Neurological Disorders and Stroke guidelines for intravenous thrombolysis with tissue plasminogen activator. As in western communities, our pre-hospital emergency referral systems for acute stroke require substantial improvements including the wider use of ambulance calling. Although our in-hospital stroke management is functioning relatively well, further efforts are necessary in reducing the diagnostic delay.