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Introduction Fusiform basilar aneurysms represent a small group of patients of intracranial vascular disease at 0.1% incidence in autopsy series. It has a high mortality of 30–40% and if left untreated, significant interval growth (approximately 50%) is seen in patients over follow-up periods. Treatment poses a high risk, therefore physicians and patients also often faced with a tough decision regarding treatment options.Aim of study We analysed the outcomes of a long series of patients treated in a world-leading centre.Method Retrospective analysis was completed of patients treated at our centre. The primary radiological outcome was related to aneurysm stability (reduction in size or no change in size) or increase in size. Clinical outcomes were assessed by post-treatment mRS shift, rate of significant complications and death.Results 70 patients were treated during a 16 year period (2008–2024). The majority of treatment was performed with a braided stent. Occlusion of the contralateral V4 segment was performed if the aneurysm extended into the VB junction.Average aneurysm diameter was 16.46mm and average disease length was 42.49mm. 13 patients (18.5%) died post-procedure due to complications or symptomatic aneurysm growth.56 patients underwent radiological follow-up, with 44 patients (78.5%) achieving good radiological outcome on average follow-up imaging period of 3.9 years. Death and aneurysm stability were significantly associated with aneurysm size and disease lengthConclusion Fusiform basilar aneurysms are a high-risk disease. This series demonstrates a decreased risk of treatment when aneurysms are smaller, potentially posing the question whether these progressive aneurysms should be prophylactically treated.Conflict of Interest Yes FI is a consultant for Medtronic and Stryker