Embolism from a stenotic lesion of the extracranial internal carotid artery (ICS) is considered to be an important pathomechanism of cerebral infarction. The purpose of this study is to estimate the risk of cerebral infarction associated with microembolism in patients with ICS and thereby to determine the importance of TCD-detected microemboli in this condition. Seventy-one cases with more than 30% ICS and 10 cases without ICS were studied. TCD monitoring was carried out for an hour at the ipsilateral middle cerebral artery of each case using a 2-MHz pulse-wave transcranial Doppler device. High intensity transient signals were counted as microemboli. Microemboli were detected in 27 of 71 cases with ICS, but not in cases without ICS. Microemboli were detected more frequently in cases with 70% to 99% ICS (53.3%) compared with in cases with 30% to 69% ICS (12.5%). Cerebral infarctions were recognized in the ipsilateral hemisphere in 23 of 27 cases with microemboli (85.2%) by means of MRI. In contrast, cerebral infarctions were recognized only in 21 of 45 cases without microemboli (47.7%). These results suggest that a stenotic lesion of the extracranial internal carotid artery, especially high-grade stenosis, is a major source of cerebral embolism and that detection of microemboli by TCD is a useful tool capable of reliably assessing the risk of cerebral infarction due to ICS.