### Learning objectives After reading this article the reader should: In western countries, stroke is the fourth leading cause of death, after heart disease, cancer and chronic respiratory diseases.1 Carotid artery disease may be responsible for 10–15% of all ischaemic strokes.2 Randomised controlled trials (RCTs) have established the benefit of carotid endarterectomy (CEA) over medical management in patients with carotid disease. In the last two decades, carotid artery stenting (CAS) has emerged as a less invasive alternative to CEA for the management of patients with occlusive carotid disease. For the purpose of this review the term ‘carotid’ refers to internal carotid artery (ICA), if not stated otherwise. ### Risk of stroke In advanced carotid disease, stroke mainly results from distal embolisation of plaque/thrombotic material into the intracerebral vasculature, while hypoperfusion as a cause of cerebral ischaemia is less frequently encountered. The latter may occur in the presence of a critical carotid lesion or occlusion and insufficient collateral circulation. Embolic and hypoperfusion-related ischaemic events may be differentiated by their clinical presentations and radiological patterns (figure 1). Embolic infarcts are caused by embolism in intracerebral arteries and are located typically at the cortical or subcortical levels. Hypoperfusion may lead to ‘border zone’ or ‘last-field’ infarcts, which are located at the cortical and subcortical levels, at the junction between vascular territories. In carotid disease, the greatest risk of (recurrent) stroke is carried by patients with a severe symptomatic lesion (ie, associated with amaurosis fugax, transient ischaemic attack (TIA) or stroke in the preceding 6 months). The degree of stenosis has been traditionally the …