Summary Twenty-four extra-intracranial revascularization procedures were undertaken in 23 patients with occlusion of the ipsilateral internal carotid artery. The superficial temporal artery was anastomosed to a cortical branch of the middle cerebral artery in 23 cases and a vein graft inserted between the external carotid artery and the cortical vessel in 1, a microsurgical technique being used. Twenty-one patients were suffering from transient ischaemic attacks (TIAs) and 2 had developing strokes. Nineteen patients had radiologically demonstrated bilateral disease of the carotid vessels, 9 having undergone contralateral carotid artery surgery before the intracranial procedure. No improvement was noted in the 2 patients with developing strokes; one patient developed a stroke contralateral to the intracranial procedure 24 h postoperatively, this being accompanied by occlusion of the anastomoses, and one patient had progression of the stroke syndrome following occlusion of the intracranial vein graft. All other patients have shown a reduction or abolition of TIAs over a follow-up period of 24 months. These findings suggest that intracranial revascularization is of value in patients with total internal carotid artery occlusion and continuing TIAs.