Transfemoral filter-protected carotid artery stenting (CAS) has emerged as a valid alternative to carotid surgery. To overcome the drawbacks of femoral access for CAS and reduce embolic load, some have proposed cervical access with internal carotid artery (ICA) flow reversal. In a series of patients at high risk for femoral access who underwent transcervical CAS with ICA flow reversal, we report clinical outcome and intraoperative embolization rates measured by diffusion-weighted magnetic resonance imaging (DW-MRI). A series of 48 patients were selected for transcervical CAS with carotid flow reversal from September 2004 to July 2007. The indications used for this technique were age >or=80 years, severe aortic and epiaortic vessel tortuosity, widespread calcification of aortic arch or epiaortic vessels, severe aortoiliac occlusive disease, large abdominal aortic aneurysm, and aortobifemoral prosthesis. During the procedure, no adjunctive maneuvers such as external carotid artery balloon occlusion were used. Of the 48 patients, 43 underwent preoperative and postoperative cerebral DW-MRI. The death/stroke rate in the 48 patients was 2.1% (one transient ischemic attack, one minor stroke, and no deaths). None of the procedures led to carotid dissections or access-site complications. Of the 43 patients who underwent DW-MRI, 16 new ischemic lesions were disclosed in six patients (13.9%), four (9.3%) of whom remained asymptomatic. All ischemic lesions were ipsilateral to the treated carotid artery. In patients at high risk for the transfemoral approach, transcervical carotid stenting with flow reversal achieves good technical and clinical results and seems able to reduce the incidence of postoperative DW-MRI ischemic lesions previously reported for transfemoral filter-protected CAS.