A 50-year-old male presented with severe atherosclerotic stenosis of the basilar artery at its origin with very poor blood flow distally, manifesting as sudden onset of deterioration of consciousness to semicomatose with decerebrate posture. He regained consciousness dramatically after acute thrombolysis, although right hemiparesis persisted due to left pontine infarction. Follow-up angiography after 3 months of antiplatelet and anticoagulation therapy demonstrated severe residual stenosis of the basilar artery. Percutaneous transluminal angioplasty (PTA) resulted in wide patency of the basilar artery stenosis with excellent blood flow distally. Combination of acute thrombolytic therapy and subsequent PTA is an effective treatment for severe basilar artery occlusive disease.