Carotid artery stump pressure was measured in 84 cases of carotid endarterectomy. The operations were performed in 71 patients over a period of five years. An altered neurological status during temporary occlusion of the carotid artery, assessed with the patient under local anesthesia, was the sole criterion for shunt placement. Stump pressure (SP) was significantly higher in the 69 unshunted cases (mean of 53.3 mmHg) than the 15 shunted cases (mean of 34.2 mmHg). Shunt was required in two of 41 cases (5%) with SP of greater than 50 mmHg, eight of 36 cases (22%) with SP of 25-50 mmHg, five of seven cases (71%) with SP of less than 25 mmHg. The clinical presentation, including history of prior stroke, and the presence of contralateral disease (including complete carotid occlusion), did not influence the need for a shunt. In this series, carotid artery stump pressure has greater predictive value for shunt requirement when it is greater than 50 mmHg or less than 25 mmHg. However, monitoring the neurological status of the patient in the awake state is still the most reliable method of determining shunt requirement. In our experience, this is associated with minimal morbidity and no mortality.