To estimate the regional perfusion pressure and possibly the stump pressure during carotid endarterectomy, cerebral blood flow (CBF) measurements including a vasodilatory test were performed preoperatively. CBF was measured by 133Xe inhalation and emission tomography. An intravenous dose of 1g acetazolamide (Diamox) was used as cerebral vasodilator. Thirty-six patients with a clinical history of previous strokes (9 cases) or transient ischaemic attacks (27 cases) were studied. Nine of the patients showed occlusion of the contralateral internal carotid artery (ICA). The percent flow increase induced by Diamox in the ipsilateral hemisphere correlated to the ICA pressure was measured before clamping (n = 32, r = 0.55, p less than 0.001). In 12 of the 36 patients, Diamox caused a significant change in the flow distribution indicating a restricted regional vasodilatory capacity and a reduced regional perfusion pressure. In addition, these 12 patients showed a low stump pressure (less than 50 mmHg). However, 8 additional patients had uniform CBF increases at the Diamox test, but showed low stump pressures. It is concluded, that preoperative tests of the cerebral vasodilational capacity can be used to identify most patients with a low ICA pressure, and a substantial fraction of patients that will develop a low stump pressure upon ICA clamping during operation. In these patients with abnormal Diamox tests surgical reconstruction is particularly indicated, but, at the same time the perioperative risks are presumably highest in this group.