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Background Elderly patients with vertebrobasilar artery occlusion (VBAO) have high mortality and reduced ischemic tolerance, yet whether age modifies the effect of presentation mode, direct (‘mothership’) versus interhospital transfer, on outcomes after endovascular thrombectomy (EVT) remains unknown.Methods We conducted a multicenter retrospective analysis of consecutive VBAO patients treated with EVT over 10 years (2014-2024), stratified into octogenarians (≥80 years) and non-octogenarians (<80 years). Adjusted multivariable logistic regression with an interaction term assessed whether age group modified the effect of presentation mode on favorable functional outcome (modified Rankin Scale [mRS] 0-3) and 90-day mortality.Results Of 294 VBAO patients (median age 69 years [IQR 58-77]), 62 (21.1%) were octogenarians. Despite comparable stroke severity and recanalization rates (91.4% vs. 95.2%; p=0.3), octogenarians had significantly higher 90-day mortality (66.1% vs. 43.5%; aOR 2.63; 95%CI 1.19-6.05; p=0.02) and lower rates of favorable outcome (24.2% vs. 44.0%; aOR 0.35; 95%CI 0.15-0.81; p=0.016). The age-related disadvantage was most pronounced in the transfer pathway, where octogenarians had markedly higher mortality (aOR 4.29; 95%CI 1.61-12.36; p=0.005) and lower odds of favorable outcome (aOR 0.17; 95%CI 0.05-0.50; p=0.002), while no significant age differences were observed within the mothership pathway. Age significantly modified the effect of transport strategy on favorable outcome (P-interaction=0.024): mothership presentation favored octogenarians (mRS 0-3: 38.9% vs. 18.2%) compared to non-octogenarians (46.6% vs. 37.7%) ( table 1, figure 1). No significant interactions were observed for sex, IV thrombolysis, last-known-well to arrival, or baseline NIHSS.Conclusions Age is a critical modifier of prehospital transport strategy in VBAO thrombectomy. Direct transport to thrombectomy-capable centers appears to maximize functional recovery in octogenarians, while younger patients fare comparably or better with transfer. These findings highlight the heightened time sensitivity of elderly, frail brains and support age-aware triage protocols to optimize EVT delivery.Disclosures A. Al-Qudah: None. T. Yelam: None. A. Al-Bayati: None. D. Haussen: None. N. Bhatt: None.Abstract O-013 Table 1Outcomes by presentation mode stratified by age groupAbstract O-013 Figure 1Adjusted associations of age and transport pathway with 90-day outcomes after EVT for vertebrobasilar occlusion. Models were adjusted for baseline NIHSS, sex, pc-ASPECTS, and last-known-well to arrival time. For age comparisons, odds ratios >1 indicate higher odds of mortality or worse outcomes in octogenarians. For pathway comparisons, odds ratios >1 favor mothership presentation. Vertical dashed line denotes the null value (OR=1). aOR, adjusted odds ratio; aCOR, adjusted common odds ratio; mRS, modified Rankin Scale