Introduction Stroke and stroke related disabilities secondary to extracranial carotid artery disease, remains an important public health problem. Since several clinical trials have proved the benefit of carotid intervention in patients with moderate or severe stenosis, imaging of the carotid artery has been the focus of considerable attention. Angiography has been considered the gold standard examination; however it is an invasive procedure and the frequency of reported neurological complications, including stroke, varies from 0.45% to 2.6%. To reduce risks related to catheter based angiography, many noninvasive imaging approaches have been advocated.2D Duplex ultrasound is able to overcome some of the problems of the conventional angiography and has been used either as an adjuvant examination of surgical candidate selection, However 2D Imaging have some limitations. Aim of work Is to study the role, diagnostic accuracy and efficacy of 3D imaging techniques (3D power Doppler sonography and 3D CE-MR angiography) in the assessment of carotid artery lesions as compared to 2D Doppler ultrasound. The impact of these less invasive imaging modalities has resulted in the reduced need and benefit of catheter based angiography.Methods The present cohort study included 60 patients (39 males and 21 females) with a mean age of 59.1 years (range 11 – 78 years) who were referred for assessment of their carotid arteries, most commonly presenting with cerebrovascular stroke or transient ischemic attacks. All the patients underwent preliminary 2D duplex scanning then 3D power Doppler and 3D contrast enhanced MR angiography. Results A total of 63 stenoses of various degrees (range from 20 to 100%), three ulcerated plaques, one dissection, one aneurysm and two hemodynamic significant kinks were diagnosed.Our results revealed that both 3D power Doppler sonogram and 3D CE-MR angiography showed excellent agreement as regards estimation of the degree of stenosis as well as the distance of the stenosis or occlusion from the bifurcation, when compared to 2D Doppler sonography. 3D CE-MR angiographic images showed comparable lesion lengths to that estimated by 2D color duplex sonography, however 3D power Doppler scanning detected significantly shorter lesions. 3D CE-MRA appeared to be the most accurate method in detection of carotid ulcerations. Conclusion We conclude that both 3D CE-MRA and 3D power Doppler sonography are accurate methods to assess carotid artery disease. They can be used reliably as complementary methods to 2D color duplex sonography that add valuable information in diagnosis of carotid artery stenosis and selection of candidates for carotid endarterectomy. The present study suggests the following work up for patients who are advised for carotid artery evaluation. A 2D duplex scanning should be performed and if any abnormality is detected, we can proceed in the same setting to perform 3D power Doppler reconstruction as it provides more information of the anatomical location and the lesion morphology. However if the 2D duplex study shows significant stenotic lesions, suspected ulcerated plaques, heavily calcified plaques, or suspected tandem lesions we may proceed to perform 3D CE-MR angiography. Contrast angiography is thus only reserved for the rare patients with non-diagnostic CE-MRA quality.