Chronic kidney disease is a common comorbidity in patients presenting to emergency departments with acute ischemic stroke. There are numerous considerations that must be taken into account in the acute diagnosis and management of these patients. CKD patients may have different stroke presentations compared to the general population that may make diagnosis more challenging. With the expanding use of endovascular thrombectomy for acute ischemic stroke, more contrasted studies are being employed as part of the acute evaluation, particularly in the identification of patients with large vessel occlusion and demonstration of salvageable penumbra. For most patients with renal dysfunction, studies such as CT angiography and perfusion may still be performed despite concerns of acute kidney injury. Although patient outcomes with reperfusion therapies such as intravenous alteplase and endovascular thrombectomy are not as robust as those seen within the general population, the available data supports utilization of these therapies among CKD patients. This article provides a review of the factors that must be considered in the acute management of the CKD patient presenting with acute ischemic stroke.