Although surgical treatment of the stenotic and ulcerative internal carotid artery has been accepted as an effective approach to the management of cerebrovascular insufficiency, uncertainty and controversy have prevailed over the past two decades regarding the optimal management of the totally occluded artery. Over a 10-year period, 47 thromboendarterectomies were performed for recent total occlusion of the internal carotid artery. The patients were categorized and selected for surgery according to their neurologic manifestations and clinical status. Postoperative patency was studied by angiography and noninvasive laboratory tests, including oculoplethysmography, carotid phonoangiography, Doppler ultrasound, and ultrasonography. The patency rate achieved appeared to be related to the duration of carotid occlusion (100% within 7 days and 50% at 1 month). The overall patency rate was 68%. There were no operative deaths or morbidity. Dramatic improvement occurred in three patients who underwent surgery immediately after the onset of a major neurologic deficit. The results of this study indicate that surgical treatment for internal carotid occlusion should be considered in selected circumstances. Careful case selection and judicious timing of operation are mandatory.