Acute internal carotid artery (ICA) occlusion may result in severe disability or death. Revascularization by carotid artery stenting after treatment with intravenous (iv) recombinant tissue-type plasminogen activator (rt-PA) has been documented. However, there are few reports on emergency carotid endarterectomy (CEA) within 24 hours after the iv administration of rt-PA. We treated a 58-year-old man with right ICA occlusion with iv rt-PA. Although partial recanalization of the ICA was obtained, severe stenosis at the origin of the ICA persisted and he developed fluctuating neurological deficits. To prevent progressive stroke he underwent CEA 10.5 hours after rt-PA treatment. Thereafter his blood pressure was strictly controlled under sedation. During and after CEA there were no hemorrhagic complications. Our findings suggest that emergency CEA may be an option to address symptomatic severe residual ICA stenosis even after iv rt-PA therapy delivered in the acute stage. J. Med. Invest. 63: 300-304, August, 2016