Atherosclerotic disease of the extracranial vessels is a frequent cause of cerebral ischemia and stroke. Many natural history studies and prospective treatment trials with large patient samples have focused on optimal patient assessment in regard to medical or interventional measures. Clinical decision making nowadays is largely based on the identification, visualization, and grading of the local stenosis, and the identification of neurologic symptoms related to carotid artery stenosis. MRI already has contributed considerably as many surgeons no longer require preoperative conventional contrast angiography but may use the combination of duplex ultrasound studies and MRA for visualization of the pathology. Besides MRA improvements, DWI and PWI are increasingly used in addition to conventional MR contrasts (PD, T2-, T1-weighted MRI) in attempts to gather information on tissue status and the pathophysiology of hemodynamic compromise and cerebral ischemia in patients with carotid artery stenosis. Obtaining background information using this array of MR data may eventually become a basis for optimal risk-benefit assessment in patients with carotid artery stenosis.