Abstract Atherosclerosis is a chronic inflammatory condition of the arteries, marked by the development of plaques within the arterial intima. The rupture of unstable plaques can lead to thrombosis, downstream vessel occlusion and serious clinical events. The composition of atherosclerotic plaques is complex and highly heterogeneous, posing challenges for their study. The current pathology and histological subtype classification of plaques may fail to fully encompass the microscopic molecular components in the tissue, the disease progress in various stages of atherosclerosis and the potential mechanism of plaque rupture. However, spatial mapping of the heterogeneity in plaque tissue components can enhance our understanding of these lesions. Despite the considerable progress made by traditional omics in the field of disease research, and its status as an indispensable technology, there remain inherent limitations in the investigation of minute molecular. In recent years, spatial omics techniques have advanced significantly, enabling the visualisation and analysis of specific components within plaques that may serve as causal targets associated with disease progression. The effective application of spatial omics in both research and clinical settings represents a promising area for further exploration. This review focuses on the recent advancements and findings related to spatial omics in the study of extracranial carotid atherosclerotic cerebrovascular disease. Spatial omics analysis of atherosclerotic plaques can facilitate the detection of biomarkers with diagnostic significance or potential relevance to disease, offering new methods and insights into the diagnosis of atherosclerosis and its complications.