Recent evidence indicates that the risk of stroke symptoms in non-operated medically managed patients with asymptomatic severe carotid stenosis has fallen significantly over the last 25 years. This suggests concurrent improvements in vascular disease medical intervention efficacy. If the latest estimates of average annual stroke rate for non-operated patients are reflective of contemporary medical intervention and surgical stroke/death rates match those of the randomised trials, the current implication is that carotid surgery will not offer a stroke prevention advantage over medical intervention alone. Furthermore, it is still not possible to identify patients with asymptomatic severe carotid stenosis with a higher than average ipsilateral stroke risk despite current medical intervention. Even if such patients were one day reliably identified, they could also be at higher risk of stroke/death from instrumental intervention (surgery, angioplasty or stenting) and randomised trials will be required before being justification in routine clinical practice.