BACKGROUND: Endovascular repair of the basilar artery bifurcation ruptured aneurysms (BABRA) is the preferred approach over surgical clipping, as clipping is associated with a higher chance of mortality and morbidity. Additionally, surgical clipping is not offered to those with poor Hunt and Hess grades (HandH). Limited data exists on the outcomes for those with grade IVandV of ruptured BABRA, leading to uncertainty regarding aneurysm repair. The objective of our study is to report the outcomes of patients with BABRA including those with poor grades, underwent endovascular repair. METHODS: 24 consecutive patients who had endovascular repairs of BABRA from Jan 2011 to Dec 2020 were enrolled. Patient data collected included: demographics, HandH grade, Fisher scale, size of BABRA, and perioperative events. 90- day outcomes were measured using the modified Rankin scale (mRS). Radiographic outcomes were measured using digital subtraction cerebral angiography with Raymond-Roy occlusion classification of intracranial aneurysms. RESULTS: Twenty-four patients with a median age of 54, underwent endovascular repair of 24 BABRA; median size of 11 mm (4 to 30 mm), wide-neck in 14 patients. Presenting HandH grades was as follows: I in 29%, II in 25%, III in 17% and IV in 29%. 13 patients required external ventricular drain (EVD) and 9 required stent-assisted coiling in acute phase Immediate complete or near complete obliteration achieved in 79% and subtotal in 21%. At 90 days, 75% of patients showed a good outcome (mRS 0 in 14, mRS 1 in 2, mRS 2 in 2) and 25% showed a poor outcome (mRS 3 in 3, mRS 4 in 3, mRS 6 in 1). Of those poor grades HandH IV (7 patients), 57% had good outcomes (mRS 0 in 2, mRS 1 in 2). Recanalization was observed in 9 patients (37%) (1 in small 1, 5 in large and 3 giant), in large and giant aneurysms. Recurrent cases were repaired (5 stent-coil, 4 coiling) without any event and had no impact on their clinical outcomes. There were perioperative complications in 2 patients (one patient developed pontine stroke and achieved mRS 3 and other EVD-related subarachnoid hemorrhage who presented with a HandH of IV, never improved). CONCLUSION: Endovascular therapy for BABRA is associated with low perioperative risk and good outcomes, including those presented with a poor grade. Endovascular therapy should be considered for all BABRA irrespective of the severity. A high rate of recurrence was observed in large, giant, and partially coiled aneurysms that were repaired and achieved good outcomes. Therefore, all large, giant and partially coiled BABRA warrant an early evaluation for recurrences. Further studies are required to delineate the standard of care for BABRA. BABRA: basilar artery bifurcation ruptured aneurysms EE: endovascular embolization ET: endovascular therapy EVD: external ventricular drain HandH: Hunt and Hess ICA: intracerebral aneurysms mRS: modified Rankin Scale PCA: posterior circulation aneurysms