Injuries of the internal carotid artery at the skull base present complex technical problems for the surgeon. Exposure is difficult, distal control of the vessel for shunting or repair is frequently impossible, and thus ligation of the ICA is often necessary as definitive treatment. Three cases involving penetrating injury to the carotid artery at the skull base are presented. The issue of primary repair vs. ligation for carotid injuries is briefly addressed, and the various methods of surgical exposure of the distal extracranial ICA are reviewed.

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