Clinical decision making is often difficult in very old stroke patients, partly because there is little systematic information on clinical course and outcome available. In a population-based sample of 953 consecutive patients admitted to hospital for acute stroke, 79 (8.3 %) were ≧ 85 years of age. Patients over 85 years more often had a history of cardiac failure (p < 0.001) or atrial fibrillation (p < 0.001) than those less than 85, but the two age groups did not differ in the occurrence of previous stroke, myocardial infarction or diabetes. The frequency of hemorrhagic stroke was similar in the two groups, but a diagnosis of cerebral embolism was more common in patients ≧ 85 years (49 vs. 29%; p < 0.001). On admission, the very old patients more often presented with lowered consciousness, impaired motor function, aphasia and urinary incontinence, and they had significantly lower diastolic blood pressure levels throughout the acute phase. The 30-day case fatality rate was 25% in patients ≧ 85 years and 12% in patients < 85 years (p < 0.01). Of the survivors, 51 and 71 %, respectively, were discharged home (nonsignificant). In a multiple regression model, age ≧ 85 years was a very weak predictor of early case fatality rate after adjustment for other, more significant predictors.