Background <p>Acute carotid artery occlusions have a high clinical importance with high mortality and morbidity.</p> Objective <p>In view of the sparse evidence, the question arises as to the correct treatment approach in acute cases.</p> Material and methods <p>Evaluation of meta-analyses and case reports as well as discussion of fundamental research.</p> Results <p>Systemic lysis of carotid occlusions has relatively low rates of recanalization but if administered early this number can rise to 30%. Endovascular treatment has been shown to have much higher success rates and has become the standard treatment for carotid artery occlusions. Surgical recanalization has not been established for carotid artery occlusions, although it has proven effective in specific individual cases. Good clinical outcomes have also been described with the use of hybrid procedures, utilizing a&#xa0;combination of surgical and endovascular techniques even for complex occlusion patterns.</p> Conclusion <p>The management of this highly complex pathology should always be adapted to the individual patient and should be determined and carried out in an interdisciplinary process. Endovascular treatment has become established as a&#xa0;safe and effective method. The surgical treatment alone should only be considered in specific individual cases but has a high potential as part of hybrid procedures, especially in challenging cases.</p>