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Abstract: Background: It is still difficult to directly prove the involvement of hemodynamic ischemia in ischemic attacks in patients with occlusive carotid artery diseases. Case Description: In this report, we describe the case of a 52-year-old woman with right ICA occlusion who experienced repeated transient weakness of the left extremities during HD for chronic renal failure. Single-photon emission computed tomography showed reductions in CBF and CVR to acetazolamide in the right hemisphere. Real-time NIRS monitoring clearly showed a deterioration in the cerebral oxygenation state in the right hemisphere in response to a BP decrease during HD. Superficial temporal artery–MCA anastomosis improved SPECT as well as NIRS findings and resolved ischemic attacks during HD. Conclusion: This is the first study to show that NIRS can be a useful tool in detecting hemodynamic ischemia in patients with impaired cerebral perfusion reserves noninvasively and in real time. [Copyright &y& Elsevier]