Although duplex carotid imaging is a safe diagnostic procedure, 3 neurologic and 2 cardiac adverse events have been associated with its performance in the past twenty-five years. This is a report of a man who had a transient cerebral ischemic attack during duplex imaging. An intraarterial digital subtraction angiogram showed 50% stenosis of the left internal carotid artery and 30% stenosis of the right internal carotid artery. Magnetic resonance imaging showed multiple small infarctions in both cerebral hemi spheres and the brainstem. At left carotid endarterectomy, the atherosclerotic plaque removed had several small ulcers.
