Introduction: It has been postulated that up to 11 million silent strokes occur annually. While these patients are without classic neurologic deficits, they may exhibit cognitive decline. In this study, we examine the cognitive function of patients with carotid stenosis. Additionally, we evaluate a noninvasive measure of strain in pulsating carotid artery plaques to determine its ability to predict cognitive decline. Methods: We administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) to 44 patients with carotid stenosis. All patients had stenosis meeting NASCET or ACAS criteria for endarterectomy, and were classified as symptomatic or asymptomatic as defined by these publications. Age-adjusted scores for each of the 5 RBANS domains (immediate memory, visuospatial ability, language, attention, and delayed memory) were compared between symptomatic and asymptomatic patients. Mean score for each of the 5 domains was then compared to all other domains, regardless of symptom status. From this cohort, 23 patients underwent assessment of carotid plaque strain by tracking displacements in ultrasound radiofrequency data to estimate axial and principal strains over the cardiac cycle. Results: Thirty symptomatic and 14 asymptomatic patients were studied. Visuospatial scores were significantly lower than any other domain regardless of symptoms (p < 0.05 for all pairwise comparisons). No other domain score was significantly different from any other. In the language domain, asymptomatic patients scored significantly higher than symptomatic patients (p < 0.05. For all other domains, no difference was found. Asymptomatic patients showed a relationship between plaque strain and immediate memory (r = -.61, p = ns). Left carotid disease was associated with poorer performance across multiple cognitive domains with increasing accumulated strain. This was not seen in right carotid disease. Conclusion: Patients with large carotid plaques (> 70% stenosis) exhibit significant difficulties in mental status whether classically symptomatic or asymptomatic. While language deficits may be a non-specific marker for stroke symptoms, visuospatial deficits are seen before classic symptoms, suggesting that carotid disease may become symptomatic earlier and more subtly than previously suspected. Abnormal strain distribution with pulsation may be related to cognition. © 2012 Elsevier B.V.