Objectives: In the present study we measured carotid plaque morphology and plaque area by Duplex Doppler ultrasonography (US), as well as angiographic extent of carotid artery stenosis referred for carotid arteriography (DSA) in patients with two or more atherosclerotic risk factors, to assess the relation between features of carotid artery disease (CAD) and presenting cerebrovascular symptoms directly in the elderly. Methods: Some 74 symptomatic (transient ischaemic attack (TIA) 17, amaurosis fugax 34, transient stroke 4, established stroke 10, progressive stroke 9) and 52 asymptomatic patients were studied with US and DSA. All patients was of 60–85 years old. Carotid plaque morphology (echolucent, echogenic or complex) and plaque area were assessed with US, and luminal stenosis was measured with DSA. Spearman correlation analysis was performed to identify the association between characteristics of CAD and presenting symptoms. Results: Symptomatic patients with echolucent and complex plaque were common than that with echogenic plaque (P < 0.05 and P < 0.01 respectively). With advanced plaque area and degree of carotid luminal stenosis, the incidence of general symptom had increased significantly, but percentage of patients with regular treatment had decreased gradually. Spearman correlation analysis confirmed that presenting symptoms was in direct correlation with Carotid Plaque Area (P < 0.05) and carotid luminal stenosis (P < 0.05), but was in negative correlation with regular treatment of cardiovascular risk (P < 0.01). Analysis showed that features of CAD did not distinguish between types of symptomatic patients. Conclusions: There was an association between features of CAD and the presence of symptoms but not their type in the elderly. Identifying high risk elderly patients of CAD and giving regular treatment earlier might stabilize the plaque, reduce the plaque area and the progression in luminal stenosis, then decline or prevent the incidence of presenting cerebrovascular symptoms.