Neurosurgeons are frequently involved in choosing an antiplatelet therapy for their patients in the perioperative period. New data obtained from the Aspirin and Carotid Endarterectomy (ACE) Trial suggest that low-dose aspirin is superior to high-dose aspirin therapy in reducing rates of perioperative stroke and death. The ACE-related data are reviewed, and the authors provide an update on current Food and Drug Administration-approved antiplatelet therapies for secondary stroke prevention, as well as a summary of antiplatelet therapies being developed.