Ninety-seven patients undergoing 103 carotid operations were studied intraoperatively using somatosensory evoked potentials after median nerve stimulation (SEP) and transcranial Doppler sonography (TCD). SEP were recorded from the scalp (C3'-Fz or C4'-Fz) and from the second cervical vertebra. The amplitude of the primary cortical response (N20P25) was measured peak-to-peak. Central conduction time (CCT) resulted from the difference between the first negative cortical (N20) and cervical (N14) response. TCD was performed using a pulsed 2-MHz-Doppler device to record the mean blood flow velocity of the middle cerebral artery (Vm-MCA) transtemporally. TCD and SEP variables were registered prior to and after carotid clamping, at short intervals during the clamping period, and after declamping. Critical SEP alterations (N20P25 less than 50% and/or CCT greater than 20% compared to the preceding values) were regarded as significant indicators of cerebral ischaemia, and selective intraluminal shunting was generally based on SEP criteria. The incidence of critical SEP changes was compared to Vm-MCA reductions greater than 60% using the Chi2-test. With SEP always recordable, additional TCD monitoring was possible in only 78 patients in our series for technical or anatomical reasons. Vm-MCA reductions greater than 60% were associated with critical SEP alterations in six cases. In five patients, Vm-MCA was reduced greater than 60% without relevant SEP changes, whereas one patient with critical SEP findings had only a minor Vm-MCA reduction (33%). In the remaining 66 cases, carotid clamping was tolerated without critical SEP changes associated with Vm-MCA reductions not exceeding 60%.(ABSTRACT TRUNCATED AT 250 WORDS)