Carotid bifurcation stenosis is an important cause of ischaemic stroke, particularly in patients with recent transient ischaemic attack or minor stroke. Large randomised trials of endarterectomy have shown that surgery reduces the risk of stroke in patients with > or =50% recently symptomatic carotid stenosis, but more recent research has shown that the effectiveness of surgery is highly dependent on timing and on patient selection. Early surgery has been shown to be essential to reduce the high risk of stroke in the first few weeks after a TIA or minor stroke, and targeting treatment on the basis of timing and individual risk modelling has been shown to be useful in selecting patients with most to gain from endarterectomy for symptomatic stenosis. This article reviews current understanding of the high-risk period after TIA and minor stroke and recent developments in the identification of the high-risk patient - both in the acute phase and in the long-term.