Carotid endarterectomy is most successful in younger patients who have >75% stenosis. Effective medical therapy includes anticoagulation, blood pressure control and normoglycemia. Isradipine is a new anti-atherosclerotic agent. Neuroradiologic techniques are increasing in number and inventiveness. Isoflurane remains the agent of choice although propofol may increase cerebral protection. Aggressive postoperative care of poor-grade aneurysm by volume expansion improves outcome.