Abstract Stroke is the principal cause of persisting neurological disability in the ‘developed’ world. The most common cause of ischaemic carotid territory stroke is thromboembolism, usually from stenoses in the extracranial internal carotid artery. In the majority of patients, embolism is preceded by an acute change in plaque morphology, thus predisposing to overlying thrombus formation. The management of symptomatic atherosclerotic carotid artery disease requires modification of risk factors, and antiplatelet and statin therapy. There is grade-A level evidence that selected patients (usually those with a stenosis >70%) gain significant benefit from carotid endarterectomy (despite the small risk of perioperative stroke). Two level-I randomized clinical trials have also provided grade-A evidence that patients with asymptomatic carotid stenoses >60% gain significant benefit from carotid endarterectomy (although the overall reduction in late stroke is less than that observed in symptomatic patients). Emerging as a possible alternative to carotid surgery is angioplasty; the extracranial stenosis is dilated and primarily stented via the Seldinger approach through the common femoral artery (thereby potentially avoiding some of the complications associated with carotid surgery). Most practitioners of angioplasty use a cerebral protection device to minimize the risk of embolic stroke during the procedure.