Duplex ultrasound (US) scans of 110 carotid arteries ipsilateral to hemispheric strokes were compared with scans of 90 asymptomatic vessels in the same patients to determine the relative prevalence of stenotic lesions. In addition, scans of paired carotid arteries in patients with stroke involving only one cerebral hemisphere were compared to determine whether the incriminated side demonstrated a greater degree of stenosis than the asymptomatic side. The duplex US findings demonstrated a positive correlation between stenosis and hemispheric stroke. However, only 20% of carotid arteries ipsilateral to hemispheric stroke showed a reduction in diameter greater than 70%, compared with 5% of asymptomatic vessels. A minimal difference was demonstrated between the symptomatic and asymptomatic groups with respect to lesser degrees of stenosis. In paired carotid arteries, the degree of stenosis of the symptomatic vessel exceeded that of the asymptomatic vessel in only 43% of cases. These results suggest that the prevalence of severe carotid stenosis in stroke patients has been previously overestimated. The findings also emphasize the need for further investigation of other plaque-related risk factors that may enhance stroke prevention through improved selection of surgical or medical therapy. Factors currently under investigation include plaque ulceration, intraplaque hemorrhage, plaque echogenicity, and the effects of sequential stenoses.