The perioperative management of patients undergoing carotid endarterectomy (CEA), along with attempts to prevent its associated neurologic decline, continues to be a challenge to clinicians. Due to the marked changes in cerebral perfusion, there is a spectrum of neurologic sequelae directly attributable to this procedure, ranging from intraoperative stroke and death to more subtle perioperative neurocognitive deterioration. This chapter presents a case study of a 68-year-old male with demonstrated occlusive cerebrovascular disease with a history of a right- internal carotid artery (ICA) territory transient ischemic attack (TIA) 3 months previously. Blood pressure control has long been recognized as crucial during and after CEA to prevent critical hypo- or hyperperfusion states. The performance of CEA under local anesthesia has the potential to demonstrate immediate neurologic decline. Further investigation is warranted to ensure the best neurologic outcomes in patients undergoing this common procedure.