Recently, the number of patients with severe carotid stenosis is increasing in Japan. During these 2 years (2001-2002), 205 patients with severe internal carotid stenosis were admitted to our hospital, of whom 94 patiens (45.9%) underwent carotid endarterectomy (CEA). According to our criteria of carotid ultrasound sonogram (US), we recommend the precise examination and CEA for the patients with>90% stenosis on the US axial view, over 200cm/sec in peak sysytolic velosity at the most stenotic lesion, and>1.3 in endodiastolic flow velosity ratio of common carotid artery (intact/lesion side). Transoral carotid ultrasonograpy are essential for the assessment of distal internal carotid artery, and trascranial color coded doppler ultrasonography are also useful for the management of the CEA patients to protect against hyperperfusion. Stroke internists should play the coordinator for the comprehensive assessment of the patients with systemic vascular disease with the various medical specialists, to establish the treatment strategy and management of patients with carotid artery disease.