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Stroke is the second largest cause of European cardiovascular and total mortality, largely due to atherosclerotic carotid artery narrowing or thromboembolism consequent to internal carotid artery stenosis. Current therapeutic indications suggest lifestyle interventions (smoking cessation, healthy diet and physical activity), adequate control of LDL-cholesterol and glycemic balance. It is nonetheless established that the most important factors in preventing stroke are antiplatelet therapy and blood pressure regulation. In fact, many physiological parameters, including age, drugs’ effects and especially systemic blood pressure, can be involved in maintaining cerebral blood flow through compensation for impairment of flow within carotid arteries. Many studies demonstrate the benefits of blood pressure lowering in terms of prevention of stroke, but there are conflicting data about a specific pressure target to achieve, with some evidence in favor of “the lower the better” idea, while other identifying a too low systolic blood pressure as a cause of cerebral ischemia worsening, especially in symptomatic patients. In summary, the available data suggest the need of a tailored blood pressure treatment without inflexible targets, according to the assessment of the cardiovascular risk of each patient, the benefits of an intensive antihypertensive therapy and the comorbidities-related response to the treatment.