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BACKGROUND Test balloon occlusion (TBO) is important in the management of complex cerebrovascular and skull base lesions when permanent occlusion (PO) of a parent artery may be indicated. Several adjuncts may be used to increase the sensitivity of TBO to predict whether PO will be tolerated. OBJECTIVE This is an observational study to evaluate the utility of internal carotid artery (ICA) TBO using single photon emission CT (SPECT) in the management of complex vascular pathology and skull base tumours. METHODS All TBO procedures performed over a 20-year period were analysed. Clinical assessment and angiographic collateral flow were combined with semi-quantitative cerebral blood flow analysis using technetium-99m HMPAO SPECT during ICA TBO. Evaluation of collateral circulation following TBO; the complications of TBO and the safety of PO following successful TBO were evaluated. RESULTS 83 patients underwent TBO without complication. Of 45 patients with satisfactory TBO, 28 proceeded to PO. Three patients developed transient ischaemic symptoms thought to be embolic in origin. 38 patients had unsatisfactory TBO, of whom 15 required PO accompanied by a bypass procedure. 40 patients in the series did not undergo permanent vessel occlusion. CONCLUSIONS SPECT-enhanced TBO is an important component of the management of complex vascular pathology and skull base tumours, permitting safe PO of the parent vessel and definitive treatment of the main pathology.