The indications for shunt placement to prevent cerebral ischemia during carotid endarterectomy have been controversial. Some investigators have recommended empiric shunting for patients presumed to be at higher risk for cerebral ischemia with a recent stroke or severe stenosis or occlusion of the contralateral internal carotid artery. Carotid endarterectomy was performed in 81 cases with cervical block anesthetic, monitoring the awake patient for the development of cerebral ischemia (unresponsiveness or paralysis) during carotid clamping. The need for shunting (based on awake response) was compared in patients with the arbitrarily defined empiric indications for shunting (n = 29) versus those who did not have such clinical or anatomic findings (n = 52). Cerebral ischemia requiring shunting was observed in five (17.2%) of 29 cases with the defined indications for empiric shunting. This was not different than the need for shunting in the control group where cerebral ischemia was seen in eight (15.4%) of 52 cases. No intraoperative neurologic events occurred in any case, but one (1.2%) patient suffered a postoperative transient ischemia attack and another (1.2%) had a postoperative stroke. Empiric clinical or anatomic indications for shunting were not reliable predictors of cerebral ischemia that developed during carotid clamping in this study. Awake patient monitoring during carotid endarterectomy with regional anesthetic allowed prompt, accurate identification of patients with cerebral ischemia who would clearly benefit from placement of a shunt.