Although there is a lack of randomized data, what is clear is that, although variable, basilar occlusion can be catastrophic and the outcome is better in patients who are treated with recanalization therapy. Patients with more distal occlusions of embolic etiology and with poor collateral flow do badly without treatment. Large clot loads are difficult to treat, even with IAT, and mechanical methods of extraction/aspiration may be needed to facilitate recanalization. Patients with a depressed level of consciousness (although a marker of poor prognosis) may still do well with treatment despite the presentation. Treating patients early is optimal, although delayed treatment may still be successful and exclusion from treatment based strictly on timing is not warranted. Perhaps assessment of pretreatment infarct core with diffusion-weighted MR imaging or CTASI will be a useful tool in selecting for aggressive therapy those patients who present late or who have clinically severe strokes. We suggest that the recanalization rates of IAT and mechanical devices are generally higher relative to IVT, and it is not unreasonable to assert that, for acutely unwell patients with poor prognostic indicators and heavy clot loads, endovascular therapy is currently the only way to achieve effective recanalization satisfactorily in the majority of patients.