Carotid plaque surface morphology appears to play a controversial role in the occurrence of cerebrovascular symptoms, that is, amaurosis fugax, transient ischemic attacks, and episodes of stroke. A number of researchers favor a strong association between the morphologic abnormalities of the carotid plaque surface and the development of cerebrovascular symptoms. The supporters of this theory have demonstrated that surface contour irregularities not only are important potential sources of flow abnormalities but also contribute significantly to the development of ischemic neurologic symptoms through plaque fragmentation, microthrombi formation, and atheroembolism. However, opposers of this theory also exist. The main arguments for and against this theory, as well as the possible underlying pathomechanism linking the morphology of the carotid plaque surface with the development of cerebrovascular symptoms, are outlined. Detection of carotid surface abnormalities with the aid of angiography or color-flow duplex ultrasonography should play a major role in the early identification of patients at increased risk, this way aiding prompt correction of these usually clinically silent but potentially hazardous lesions.