IntroductionEndovascular stroke treatment (EST) is commonly performed for acute basilar artery occlusion (BAO). We aimed to identify the role of the exact location of BAO in patients receiving EST regarding the stroke etiology, recanalization success and prediction of favorable clinical outcome.MethodsRetrospective analysis of 191 consecutive patients treated for BAO with EST from 01/2013 until 06/2021 in a tertiary stroke center. Groups were defined according to exact location of BAO in I: proximal third, II: middle third, III: distal third and IV: tip of the basilar artery. Univariate and multivariate analyses were performed for BAO location comparing stroke etiology, recanalization result and favorable clinical outcome according to mRS 0–3 90 days after stroke onset.ResultsOcclusion sides types I–IV were evenly distributed (37, 36, 60 and 58 patients). Types I and II were more often associated with large artery atherosclerosis (50 vs. 10 patients,p< 0.001). Distal/tip occlusion (types III/IV) occurred mostly in cardiac embolism or embolic stroke of unknown source (89 vs. 12 in types I/II,p< 0.001). Occlusion site correlated with the underlying stroke etiology (AUC [Area under the curve] 0.89,p< 0.0001, OR [odds ratio] for embolism in type IV: 245). Recanalization rates were higher in patients with distal occlusions (type III/IV OR 3.76, CI [95% confidence interval] 1.51–9.53,p= 0.0076). The BAO site is not predicting favorable clinical outcome.ConclusionThe exact basilar artery occlusion site in patients eligible for endovascular stroke treatment reflects the stroke etiology and is associated with differing recanalization success but does not predict favorable clinical outcome.Supplementary InformationThe online version of this article (10.1007/s00062-022-01236-0) contains supplementary material, which is available to authorized users.