The administration of intravenous thrombolytic therapy to appropriate patients and the provision of care in a dedicated stroke unit setting form the pillars of evidence-based acute stroke care. Yet, the availability of these interventions remains variable around the world. Many challenges exist for physicians attempting to set up an acute stroke service for the first time. Based upon their experience in three countries, the authors propose 12 key steps in setting up a successful acute stroke service: identify the building blocks understand local funding mechanisms forge partnerships engage senior managers obtain training be inclusive adapt to local surroundings maintain a clinical focus be incremental capitalise on the enthusiasm of others lead from the front; and provide feedback. The authors then examine some of the specific barriers that may be encountered and offer three historical examples of evidence-based interventions that were slow to be adopted. An acute stroke service is evidence-based and cost effective, yet the ability of patients to access such a service is variable, even in the developed world. By considering 12 common-sense steps, physicians and managers can maximise their chances of setting up a sustainable and successful acute stroke service.