OBJECTIVE The authors evaluated the efficacy of emergency embolectomy in patients with acute middle cerebral artery occlusion (MCAO). METHODS A retrospective review of the charts for patients undergoing embolectomy at the authors' institution was performed. Between October 1997 and May 2004, 12 patients (mean age 70 years) with acute MCAO were treated using embolectomy. Local intraarterial fibrinolysis with urokinase was initially undertaken in eight of 12 patients. Sufficient recanalization was not achieved with fibrinolysis in any patient, and thus embolectomy was performed immediately thereafter. Recanalization by embolectomy was achieved in all patients (mean occlusion time 6 hours, 11 minutes). Each patient's condition was evaluated on discharge. Outcomes in the 12 patients according to the Glasgow Outcome Scale were good recovery in five, moderate disability in two, severe disability in three, vegetative state in one, and death due to a cardiac complication in one. None of the 12 patients had symptomatic hemorrhagic infarction. CONCLUSIONS Emergency embolectomy can be performed in patients with MCAO with minimal morbidity and death. The procedure can be used to achieve good recovery even in patients in whom fibrinolysis is insufficient after acute MCAO and should be a part of the algorithm for the treatment of MCAO.