Risks associated with hypertension: Hypertension is a major factor in haemorrhagic and atherothrombotic stroke. Reduction of blood pressure reduces stroke risk by up to 40% in all hypertensive populations. Many older patients who would benefit from antihypertensive therapy are currently not adequately treated. Need for further trials: Further controlled clinical trials are required to confirm the optimum regimen for secondary prevention after a stroke or transient ischaemic attack. Knowledge of the mechanisms of ischaemic damage to the brain is increasing, and several pharmacological approaches to neuroprotection have been shown to be of benefit in experimental models. Evaluation of humans requires an accurate diagnosis of stroke type and improved outcome measures. CONCLUSIONS The optimal benefit of protection from acute strokes will depend on a better understanding of the ideal haemodynamic profile and the early and appropriate delivery of a neuroprotective drug to the site of ischaemia.