Between 1980 and 1991, 13 of 1312 carotid artery reconstructions were performed for aneurysms of the extracranial internal carotid artery. The patients included 12 men and one woman, mean age 56 years. Postoperative aneurysms and aneurysms involving the common carotid artery were excluded from the study. In six cases, the upper part of the aneurysm was higher than a line joining the mandibular to the tip of the mastoid process. Six aneurysms were atherosclerotic, two post-traumatic, four dysplasic and one post-traumatic and atherosclerotic. Nine patients had focal neurological symptoms (seven hemispherical, two ocular), one presented with cranial nerve compression, two had non-hemispherical symptoms and one was symptom-free. Surgical reconstruction was achieved by 12 venous grafts and one aneurysmorrhaphy. A conventional cervical approach was used in seven cases; in four cases subluxation of the mandible with resection of the posterior belly of the digastric muscle and division of the styloid process and its attached muscles was used. An infratemporal approach with release of the 7th nerve and opening up of the first portion of the carotid canal was used in two patients. There were no deaths or strokes but two patients had a transient ischaemic attack. In four cases, a cranial nerve palsy developed; one involving the 9th nerve did not recover. Patency was assessed by postoperative angiography in all cases. Mean (range) follow-up was 46 (4-126) months. One patient died after 2 years as a result of myocardial infarction. One patient had a transient ischaemic attack during the 2nd postoperative year. All survivors were assessed in January 1992, when all reconstructed arteries were patent.