Admission to an acute stroke unit is decided on the basis of clinical and computed tomographic data collected in emergency, leading to a risk of misdiagnosis. The aim of this study was to evaluate the rate of misdiagnoses in an acute stroke unit. This study was conducted over a 1-year period in consecutive patients, who were initially examined in the emergency department and underwent a non-contrast computed tomographic scan, an electrocardiogram (ECG) and routine biological tests. Then they were referred to the acute stroke unit, where they were re-examined by a board-certified in-house neurologist and underwent continuous ECG recording, ultrasonography and echocardiography within 24 h and other tests if necessary. Of 1,250 patients admitted to the acute stroke unit, 1,071 (85.7%) had a definite neurovascular disorder (ischemic stroke, transient ischemic attacks, intracerebral hemorrhage, cerebral venous thrombosis, subarachnoid hemorrhage and spinal stroke). 66 (5.3%) had a possible neurovascular disorder (migraine aura, post-stroke epileptic seizure, isolated acute vertigo and acute hypertensive encephalopathy), and 113 (9 %) had a non-vascular disorder, the final diagnosis was a neurological disorder in 96 of them. Therefore, misdiagnoses occur in one tenth of patients and usually consist of other neurological disorders. Therefore, neurologists should be involved in the management of stroke patients at the acute stage and should remain general neurologidts even if they are overspecialized ''strokologists.''