Purpose <p>This study assessed intravenous thrombolysis (IVT) prior to endovascular treatment (EVT) versus EVT alone in patients with basilar artery occlusions (BAO).</p> Methods <p>This patient-level pooled analysis included data from four randomized controlled trials within the VERITAS collaboration (BEST, BASICS, ATTENTION, and BAOCHE). Patients were stratified into IVT plus EVT and EVT alone. Primary outcome was favorable functional outcome, defined as modified Rankin Scale (mRS) score of 0–3 at 3&#xa0;months. Secondary outcomes included good functional outcome (mRS 0–2), mortality, and symptomatic intracranial hemorrhage (sICH) rates. Regression analyses were adjusted for covariates identified from baseline differences and univariable analyses. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to balance baseline differences and subgroup analyses were also conducted.</p> Results <p>Out of total 988 included patients, 556 patients were allocated for EVT and analyzed. No significant differences were observed between patients treated with or without IVT prior to EVT in terms of mRS 0–3 at 3&#xa0;months (47 vs 44%, adjusted odds ratio [aOR]:0.88, 95%CI 0.57–1.36), mRS 0–2 (39 vs 32%, aOR:1.22, 95%CI 0.78–1.91), mortality (33 vs 38%, aOR:0.93, 95%CI 0.59–1.44), and sICH rates (6.3 vs 4.9%, aOR:1.87, 95%CI 0.77–4.57). IPTW and PSM analyses yielded consistent results. Subgroup analyses did not reveal any differential treatment effect including time from symptom onset to imaging.</p> Conclusions <p>Findings from this patient-level pooled analysis of four randomized controlled trials suggest that bridging IVT over EVT alone was safe but not associated with significant improved outcomes.</p> Level of evidence 2b <p>Level 2b, cohort study of a patient-level meta-analysis of 4 RCT’s.</p> Graphical Abstract <p></p>