A number of new studies have provided evidence which suggests that carotid plaque surface characteristics and internal structure, as seen on ultrasonography, contribute to the development of cerebrovascular endpoints. This review is a critical presentation of the evidence that has emerged so far supporting the hypothesis that the ultrasonographic morphology of the carotid plaque may be an independent variable in predicting the risk of stroke. It is concluded that ultrasonographic plaque morphology should be used together with other local risk factors in prospective natural history studies which aim to identify a subgroup of patients at high risk of stroke.