Stroke is the third leading cause of mortality in the United States; approximately every three minutes a person will die from a stroke. Extracranial internal carotid artery stenosis (EICAS) accounts for approximately 25% of ischemic strokes, with an incidence as high as 10% in people aged > 80 years. Clinically, EICAS can manifest as a transient ischemic attack, although the vast majority of EICAS patients are asymptomatic. Symptomatic EICAS patients are at high risk for ischemic stroke if left untreated, and previous literature has shown that even patients with asymptomatic EICAS require treatment because the natural history of the disease precipitates an overall mortality rate of 4-7%. The three major treatment modalities for EICAS presently are medical management, carotid endarterectomy and carotid angioplasty with stenting. This review examines the class-I evidence (prospective randomized controlled trials) regarding optimal treatment modalities for management of symptomatic and asymptomatic carotid stenosis.