The incidence of stroke and risk factors peak in subjects > or = 75 years. Highest risk patients benefit most from effective therapy. For this reason, all strategies of proven value in stroke prevention must be assiduously applied. Control of hypertension, hyperlipidemia, diabetes mellitus and cessation of cigarette smoking are obligatory at all ages but are of special importance in the elderly. Antithrombotic drugs have been proven beneficial for patients at high risk. Lower risk subjects, including those with asymptomatic carotid artery disease, gain no proven benefit from anti-platelet drugs. Patients with non-valvular atrial fibrillation (NVAF), a condition that increases with age, require anticoagulant therapy. Strict regulation of the INR is required otherwise aspirin is recommended. Without evidence of organ failure, elderly patients with severely stenotic symptomatic carotid artery disease should receive endarterectomy. They benefit most. The evidence for benefit from endarterectomy in asymptomatic subjects at any age is weak and cannot be recommended.