Although intracranial obliteration or detachable balloon occlusion of the proximal artery has been recommended for treatment of unruptured aneurysms of the cavernous sinus, carotid artery ligation continues to be used by many neurosurgeons. This study compares the long term outcome after carotid ligation with that following conservative treatment. Nine of 13 patients treated by common carotid ligation improved, two were unchanged but two patients subsequently needed internal carotid ligation (mean FU 8.2 years). Ten patients were managed conservatively. Three improved, six were unchanged and one patient died following intracranial haemorrhage (mean FU 6.9 years). The authors conclude that carotid ligation remains an acceptable method for treating these difficult lesions.