External carotid revascularization has been advocated to correct stenoses and obliterate sources of emboli in symptomatic patients with internal carotid artery (ICA) occlusion. Of more than 450 patients undergoing carotid surgery in an 8-year period, eight patients with amaurosis fugax, hemispheric transient ischemic attacks (TIAs), or global symptoms of cerebral ischemia in the presence of ICA occlusion underwent external carotid artery (ECA) reconstruction. There were five external carotid endarterectomies and three bypasses to the ECA, one from the common carotid artery and two from the subclavian artery. There were no operative deaths, but one minor ipsilateral stroke occurred after subclavian-ECA bypass. There was complete resolution of symptoms in all the other patients. Follow-up ranged from 4 months to 10 years (mean 3.4 years). It is concluded that ECA revascularization may be the best treatment option for relieving or improving late neurologic symptoms secondary to cerebral hypoperfusion and/or embolization through ECA collaterals in the presence of ICA occlusion and ECA stenosis.