The recent review on the management of carotid atherosclerosis by Bonati et al. is a welcome and comprehensive overview of the advances in the treatment of this important cause of stroke.1 It is now thirty years since the seminal North American Symptomatic Carotid Trial, and Professor Bonati and colleagues rightly highlight the improvements in treatment over the intervening decades. However, these therapeutic advances have not been matched by developments in imaging strategies for identifying vulnerable carotid atherosclerotic plaques. Despite the importance of plaque morphology and pathophysiology in the risk-stratification of carotid atherosclerosis, imaging techniques for evaluating such processes are largely confined to research. Consequently, clinical practice remains entrenched in a stenosis-based approach to risk stratification and management.