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Background Basilar artery occlusion (BAO) is one of the most severe forms of ischemic stroke and is associated with high morbidity and mortality. Despite advances in endovascular thrombectomy and improvements in stroke systems of care, outcomes following BAO remain poor compared with anterior circulation large vessel occlusions. In this study, we evaluate clinical factors associated with 90-day mortality among patients presenting with BAO treated across multiple comprehensive stroke centers in the United States.Methods We conducted a retrospective multicenter cohort study of patients with angiographically confirmed BAO treated at 14 U.S. stroke centers. Patients with BAO who received intravenous thrombolysis (IVT) within 4.5 hours and were referred for endovascular therapy (EVT) were included. Eligibility required availability of 90-day mortality outcomes. Baseline demographic characteristics, vascular risk factors, clinical presentation, imaging findings, workflow metrics, and treatment variables were summarized and compared between patients who survived and those who died within 90 days. Multivariable logistic regression analysis was performed to identify independent predictors of 90-day mortality.Results A total of 145 patients with known 90-day mortality status were included, of whom 51 (35.2%) died and 94 (64.8%) survived. Compared with survivors, non-survivors were older (median 70.0 vs 62.5 years, p=0.046) and presented with more severe strokes-higher baseline NIHSS scores (23.5 vs 16.0, p<0.001). Non-survivors also experienced longer workflow times, including longer last-known-well-to-groin puncture intervals (265 vs 211.5 minutes, p=0.02), and required a greater number of thrombectomy passes (2.0 vs 1.0, p=0.004). In addition, diabetes mellitus was more common among non-survivors (35.3% vs 19.1%, p=0.032), and symptomatic intracranial hemorrhage occurred more frequently in this group (11.8% vs 1.1%, p=0.004). In multivariable logistic regression analysis, diabetes mellitus (adjusted odds ratio [aOR] 7.20, 95% CI 1.06-48.93, p=0.044) and higher 24-hour NIHSS scores (aOR 1.43, 95% CI 1.23-1.66, p<0.001) independently predicted 90-day mortality.Conclusions In this multicenter cohort of patients with BAO stroke, mortality at 90 days was associated with older age, greater NIHSS, longer workflow times, additional thrombectomy passes, and hemorrhagic complications. After adjustment for potential confounders, diabetes mellitus and higher 24-hour NIHSS were independent predictors of death at 90 days. Together, these findings reinforce the value of early neurological status and metabolic comorbidities, and identify modifiable care processes and procedural factors as potential targets for strategies aimed at reducing mortality.Disclosures K. Darko: None. J. Rhoten: None. C. Sidebottom: None. B. Gross: None. A. Al-Bayati: None. A. Chinthala: None. J. Burkhardt: None. K. Scott: None. V. Srinivasan: None. S. Multani: None. T. Theofanis: None. R. Zand: None. S. Bahrami: None. J. Li: None. G. Defilipp: None. D. Strong: None. R. Torabi: None. K. Moldovan: None. R. Nogueira: 2; C; GenenTech. R. Karamchandani: 1; C; GenenTech.