Symptomatic carotid stenosis is the state of carotid disease in which atherosclerotic narrowing of the internal carotid artery has caused an ipsilateral transient ischaemic attack (TIA), ischaemic stroke or retinal event. The risk of recurrent stroke is highest in the first days after the event, so assessment and treatment are urgent. Duplex ultrasound is the first test, and plaque imaging and the Carotid Artery Risk (CAR) score help to identify patients at lower risk on medical therapy alone. Every patient receives best medical therapy. Carotid endarterectomy (CEA) is added for severe stenosis and considered for moderate stenosis, and it is preferred to carotid artery stenting (CAS) soon after symptoms and in older patients. After revascularisation, patients are followed with duplex ultrasound for restenosis.