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Carotid occlusive disease may occur at the base of the skull and siphon without evidence of atheroma in the neck. Careful search for lesions in this location should be undertaken in any patients with TIAs or neurologic deficit when the extracranial carotid arteries appear normal. Unilateral frontotemporal headache may be an early symptom of stenosis in this location. Inaccessible lesions are often bilateral, although the symptoms may be unilateral. Superficial temporal-middle cerebral artery bypass on the symptomatic side affords relief of symptoms. Bypass on the contralateral side should be considered when and if symptoms subsequently develop related to the lesion on that side. The configuration of a carotid thrombus may enable one to determine that it is a retrograde rather than antegrade occlusion and hence is not amenable to endarterectomy, even in the acute situation. The use of a Fogarty catheter in such a setting would be ill-advised and potentially hazardous. Current experience suggests that risk of subsequent stroke is reduced after EC-IC bypass operation.