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Acute stroke is one of the leading causes of mortality worldwide, with venous thromboembolism (VTE) representing a significant yet under-recognized complication. The risk of VTE is highest in the early post-stroke period, driven by factors encapsulated by Virchow’s triad. However, the risk of haemorrhagic transformation following ischaemic stroke, and haematoma development and expansion after haemorrhagic stroke complicate the routine use of pharmacological VTE prophylaxis. In this review, we discuss the epidemiology and aetiology of VTE post-stroke, haemorrhagic transformation after acute ischaemic events, and the available evidence supporting mechanical and pharmacological approaches to VTE prophylaxis in these patients. Finally, we discuss the recommendations provided by the current international consensus guidelines and reasons underpinning the heterogenous management of patients in routine clinical practice, including the need for well-designed, large-scale clinical trials to better define thromboprophylaxis strategies for patients following acute stroke. [Display omitted]