Abstract Purpose To determine the radiation exposure in endovascular stroke treatment (EST) of acute basilar artery occlusions (BAO) and compare it with radiation exposure of EST for embolic middle cerebral artery occlusions (MCAO). Methods In this retrospective analysis of an institutional review board−approved prospective stroke database of a comprehensive stroke center, we focused on radiation exposure (as per dose area product in Gy × cm², median (IQR)), procedure time, and fluoroscopy time (in minutes, median [IQR]) in patients receiving EST for BAO. Patients who received EST for BAO were matched case by case with patients who received EST for MCAO according to number of thrombectomy attempts, target vessel reperfusion result, and thrombectomy technique. Results Overall 180 patients (n = 90 in each group) were included in this analysis. General anesthesia was conducted more often during EST of BAO (BAO: 75 (83.3%); MCAO: 18 (31.1%), p < 0.001). Procedure time (BAO: 31 (20–43); MCAO: 27 (18–38); p value 0.226) and fluoroscopy time (BAO: 29 (20–59); MCAO: 29 (17–49), p value 0.317) were comparable. Radiation exposure was significantly higher in patients receiving EST for BAO (BAO: 123.4 (78.7–204.2); MCAO: 94.3 (65.5–163.7), p value 0.046), which represents an increase by 23.7%. Conclusion Endovascular stroke treatment of basilar artery occlusions is associated with a higher radiation exposure compared with treatment of middle cerebral artery occlusions.