Stroke is characterized by high incidence and recurrence rates, ranking among the leading causes of mortality and disability. Currently, diagnostic and assessment approaches for stroke are associated with certain limitations, and existing clinical therapeutic strategies fail to fully address disease-specific requirements. Accumulating evidence has demonstrated that exosomes act as critical carriers mediating information transmission and targeted regulation in the pathophysiological processes of stroke. Exosomes hold promise as specific biomarkers for stroke diagnosis and prognostic assessment, while also exerting a positive therapeutic effect during disease initiation and progression. Moreover, the technology of engineered exosomes has opened a new path for the treatment of stroke, and this concept also provides new insights and methods for exerting and revealing acupuncture effects. This review summarizes fundamental research on exosomes in the context of stroke diagnosis, assessment, and relevant therapeutic mechanisms, aiming to provide insights for future investigations into stroke diagnosis and treatment.