Background Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. Also the perioperative risk might be lower by using intraluminal shunting rather than without shunt. This study aimed to assess the risks of endarterectomy under local compared with general anaesthetic. Also to assess the effect of routine versus selective or no shunting during carotid endarterectomy, and to assess the effect of different methods for selection of people for shunting. Methods We searched the Cochrane Stroke Group Trials Register (last searched August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 8, 2013), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013) and Index to Scientific and Technical Proceedings (1980 to August 2013). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field. In terms of selection criteria, randomised trials comparing carotid endarterectomy under local versus general anaesthetic. Also randomised and quasirandomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. Two review authors assessed trial quality and extracted the data independently. Main results For study in anesthetic aspect, ten randomised trials involving 4335 operations were included, of which 3526 were from the single largest trial (GALA). Meta-analysis of the randomised studies showed that there was no evidence of a reduction in the odds of operative stroke or death (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.63 to 1.16). For study in shunting, We included three trials involving 686 participants compared routine shunting with no shunting, For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. Authors' conclusions The risk of stroke and death did not differ significantly between the two types of anaesthetic technique during carotid endarterectomy. This review provides evidence to support a policy that patients and surgeons can choose either anaesthetic technique, depending on the clinical situation and their own preferences. This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. Large scale randomised trials of routine shunting versus selective shunting are required.