Occlusive disease of the vertebrobasilar system may cause a variety of syndromes depending on the artery or arteries involved and the available collateral circulation. Based on the clinical picture and the angiographic findings, some of the patients may benefit from a gross reconstructive surgical procedure in the vertebral or carotid arteries. When these arteries are not correctable by gross surgical techniques, an occipital artery-posterior inferior cerebellular artery microanastomosis may also prove beneficial. An early clinical diagnosis of the brain-stem and occipital lobes ischemia and angiographic studies of the cerebral arteries are of prime importance and the key to the surgical management of these patient.