Three different strategies should be associated for ischaemic stroke prevention in patients with internal carotid artery stenosis: vascular risk factors control, anti-thrombotic agents, and carotid revascularization. Patients are selected for carotid revascularization on the basis of the presence of clinical symptoms and degree of stenosis. The optimal indication for carotid surgery is a severe recently symptomatic stenosis, since the benefits are marginal in high-grade asymptomatic stenosis, and in moderate symptomatic stenosis. Angioplasty with endoprothesis is an alternative to surgery, but it must be restricted to symptomatic stenosis either in randomized trials, or in severe stenosis in patients in whom surgery is contra-indicated.