In developed and developing countries, the population of very old people (more than 80 years) is expected to increase over the coming decades. By 2050, there will be an estimated 56.9 million nonagenarians worldwide, an 800% increase compared with today. In this group, the prevalence and incidence of stroke is very high, with great impact on morbidity and mortality. Only 10% of survivors may expect desirable recovery, and over 50% results with severe disability, the majority of them requiring in-home geriatric care or admittance to nursing homes. In spite of this, clinical trials that investigate acute management and primary and secondary prevention drugs are scarce in this population because most of the main trials excluded patients over 80 years. Results in young patients can not be extrapolated. In the elderly population, decrease in hepatic and renal function, metabolic pathways disturbances, polypharmacy and cognitive decline affects the efficacy, safety and adherence to long-term treatments. In this issue of the journal, we will review the evidence of acute treatment (intravenous thrombolysis) in the reduction of the functional impact of ischemic events in the very old. We will also evaluate the different therapies (antihypertensive and hypolipidemic drugs) in primary and secondary prevention and discuss the management of desired blood pressure levels. We will analyze the safety, efficacy and tolerability of statin therapy in this special group. A deeper understanding of the characteristics of aged patients would facilitate a better management of their cerebrovascular events.