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Introduction Prognosis in basilar artery occlusion (BAO) is difficult to predict. Even after successful reperfusion, some patients show infarct progression, while others exhibit diffusion reversal. This suggests that pretreatment diffusion-weighted imaging (DWI) may not reflect final infarction. Thus, posttreatment DWI may correlate more closely with clinical outcomes than initial lesion patterns seen before intervention.Aim of Study This study aims to evaluate the prognostic performance of pre- and posttreatment DWI scoring systems in predicting outcomes in patients with acute BAO treated with mechanical thrombectomy.Method We retrospectively analyzed clinical and DWI data from patients who underwent thrombectomy for acute BAO. We assessed the posterior circulation acute stroke prognosis Early CT score (PC-ASPECTS), the recently developed pons-midbrain and thalamus (PMT) score, and the modified PMT score. Prognostic values of these scoring systems applied to pre- and posttreatment DWI were compared.Results A total of 126 patients with both pretreatment and posttreatment DWI were included, all of whom achieved successful recanalization. All six scoring systems applied to pre- and posttreatment DWI were significantly associated with good clinical outcomes (p < 0.001). Among these, ROC analysis revealed that posttreatment modified PMT and PMT scores demonstrated superior prognostic performance, with areas under the curve (AUC) of 0.891 and 0.888, respectively. Diffusion reversal, defined as a reduction in score, was observed in 45 patients (35%).Conclusion The PMT and modified PMT scores on posttreatment DWI demonstrated strong prognostic value for predicting outcomes in acute basilar artery occlusion after successful recanalization.Conflict of Interest No