Acute basilar artery (BA) occlusion is typically associated with poor outcome; however newer diagnostic and treatment modalities have the potential to improve prognosis. In this study, six patients with acute BA occlusion were followed and the effectiveness of local intra-arterial fibrinolysis (LIF) and subsequent percutaneous transluminal angioplasty (PTA) with a balloon catheter were assessed. Of the six patients with BA occlusion observed in this study, two had extended brain stem infarction on diffusion weighted image (DWI) and were treated conservatively. The other four patients received LIF at an average of 5.2 hours from occlusion onset. Three of these four patients received additional PTA with compliant balloon catheters. All four of the patients who received LIF achieved recanalization of the BA trunk and showed a favorable clinical outcome. These findings suggest that LIF is beneficial for selected patients with BA occlusion and that successful recanalization is indicative of a good prognosis. Because of the poor prognosis associated with conservative therapy, we conclude that LIF should be attempted even for comatose patients or in cases of prolonged occlusion time.