Discriminating brain tumor from stroke in patients presenting with acute focal neurologic signs and symptoms is crucial to avoid improper treatment, or delay correct treatment of the brain tumor patient. Data from the era before computed tomography (CT) suggests that 3% of patients with brain tumors are initially thought to have had a stroke. Our goal was to see if this has improved in the CT era. We reviewed hospital charts of all patients admitted to the Johns Hopkins Hospital with a brain tumor during a one year period. Eleven (4.9%) of the 224 patients discharged with a diagnosis of brain tumor were initially thought to have had a stroke. Seven had primary brain tumors and 4 had metastatic tumors. Patients who were originally misdiagnosed were significantly older (p = 0.01) and more likely to have a Glioblastoma Multiforme (p = 0.04) than those correctly diagnosed. Eighty-two percent of those misdiagnosed had no prior history of cancer compared to 59% of patients correctly diagnosed. Distinguishing the acute presentation of brain tumor and stroke remains an important diagnostic consideration. Physicians should recognize that while CT is frequently employed for acute neurologic deficits to exclude intracranial hemorrhage, CT may not be sufficient to exclude brain tumor. A prospective study is needed to confirm these findings.