Atherosclerotic carotid artery disease is a major contributor to the incidence of stroke, particularly in the elderly. Atherosclerosis is a systemic illness and patients often present with multisystem involvement of several vascular beds including coronary, cerebral, and peripheral vascular territories. The majority of strokes related to carotid artery disease are embolic in nature, not occlusive. Non-invasive screening tests including ultrasound, CT angiography and MR angiography are helpful in identifying pathology. However, the gold standard, for diagnosis and treatment allocation remains invasive angiography. Medical therapy to reduce the risk of stroke includes antiplatelet agents, primarily aspirin in doses of 81 mg to 325 mg per day. Control of blood pressure and the use of statin therapy is effective in reducing the incidence of stroke. Carotid endarterectomy is more effective for preventing stroke in symptomatic (transient ischemic attack or stroke) patients with = or >50% diameter stenosis and asymptomatic patients with = or >60% diameter stenosis, than aspirin therapy. In patients at increased risk for surgical complications during stroke prevention surgery (carotid endarterectomy), carotid stents have been shown to be as good or better than surgery at improving outcomes.