In the last decade, great advances have been made in the understanding of the role of lipid management in the prevention of cardiovascular disease. Epidemiological data from the Framingham study and the Multiple Risk Factor Intervention Trial (MRFIT) have described a causal relationship between lipid and lipoprotein levels and the risk of coronary heart disease (CHD). Hitherto, the emphasis of therapeutic studies has focused on coronary heart disease specifically, especially in terms of treatment with 3-hydoxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors or ‘statins’. The result has been a burgeoning evidence base demonstrating the effectiveness of statins in cholesterol reduction and, more importantly, in the reduction of coronary mortality and morbidity in subjects both with and without established CHD. Given that the vascular system is more commonly regarded as a single entity, with the pathophysiological basis of disease based on the development of atherosclerosis, it has been surprising to find that ischaemic stroke does not share the same robust relationship with cholesterol that CHD does. The lack of a consistent relationship between serum cholesterol and stroke has manifested itself in diverse attitudes towards cholesterol-lowering in cerebrovascular disease; this problem has been heightened by the relative lack of trial data and clinical guidelines on the subject. It is therefore important to review the current evidence regarding cholesterol and stroke and to derive conclusions that translate into the clinical management of cholesterol in patients with cerebrovascular disease.