Basilar artery thrombosis is an infrequent but important neurological emergency requiring early diagnosis and treatment. Of particular relevance to emergency medicine is the recognition and consideration of the unusual signs that may be present in an often previously well patient. It is therefore crucial to expedite investigations, confirm the diagnosis and commence life-saving treatment through the early involvement of a number of disciplines including neurology, radiology and intensive care. This paper confirms the use of magnetic resonance imaging and angiography as the preferred investigative mode and microcatheter directed intra-arterial thrombolysis as the treatment strategy of choice.