We report the surgical results in patients with acute cerebral main-trunk occlusion in the anterior circulation. Between April 2004 and March 2005, 26 patients were surgically treated within 24h after the onset. The occlusion occurred in the internal carotid artery in 10 patients, in the middle cerebral artery in 15, and in the anterior cerebral artery in 1. We investigated the clinical characteristics and surgical treatment and evaluated the outcome using the modified Rankin Scale (mRS). Nine patients underwent anastomosis, 14 had an embolectomy, and 3 had a carotid endarterectomy. In all the patients, revascularization was achieved, and neurological improvement was obtained. At 6 months after the onset, eight (30.8%) patients showed a good recovery (defined as grade 1 on the mRS), seven (26.9%) were rated as grade 2, eight (30.8%) were grade 3, and three (11.5%) were grade 4. Manual muscle test on admission was significantly different between the good outcome and the poor outcome groups at 6 months after onset. None of the patients experienced any complications related to the surgery. Early surgical revascularization can be an effective and safe treatment modality in appropriately selected patients with acute cerebral main-trunk occlusion in the anterior circulation.