Basilar artery occlusion is one of the most devastating neurological conditions known to man. Though rare, patients with clinical syndromes localized to this anatomical region are often referred to acute stroke and endovascular units. Recent studies evaluating the efficacy of endovascular approaches to stroke have focused on anterior circulation syndromes. In this review, we examine the approaches to stroke syndromes due to basilar artery thrombosis. We share the relevant data for intravenous and intra-arterial tissue plasminogen activator as well as mechanical approaches to restoring perfusion in this critical area of the brain.