To compare the efficacy and safety of bridging therapy (intravenous thrombolysis plus endovascular treatment) versus direct endovascular treatment (EVT) in patients with acute posterior circulation large vessel occlusion (PC-LVO). Methods: This was a single-center, retrospective cohort study. A total of 110 eligible patients with PC-LVO were enrolled, comprising 66 in the bridging group (receiving intravenous rt-PA within 4.5 hours of onset followed by EVT) and 44 in the direct EVT group [with onset-to-puncture time (OPT) extendable up to 24 hours). Clinical data were collected and compared between the two groups, including baseline characteristics such as age, sex, hypertension, diabetes, history of atrial fibrillation, admission National Institutes of Health Stroke Scale (NIHSS) score, anesthesia method, OPT, and time window stratification. The primary efficacy endpoint was the proportion of patients with a modified Rankin Scale (mRS) score of 0-3 at 90 days (good outcome). Safety indicators included the incidence of symptomatic intracerebral hemorrhage (sICH) and 90-day mortality. Multivariate Logistic regression analysis was performed to evaluate the association between bridging therapy and good outcome (mRS≤3), adjusting for baseline differences and time factors. Results: There were no statistically significant differences in baseline characteristics between the two groups except for OPT (P>0.05); the bridging group had a shorter OPT [200 (150, 240) min vs 480 (320, 720) min, P< 0.001]. The 90-day good outcome rate was 53.0% (35/66) in the bridging group and 40.9% (18/44) in the direct group, with no statistically significant difference (P=0.16). The incidence of sICH in the bridging group was slightly higher than that in the direct group (9.1% vs 4.5% , P=0.38). The 90-day mortality was 25.8% in the bridging group and 18.2% in the direct group (P=0.34). Multivariate Logistic regression analysis showed no significant association between bridging therapy and a good 90-day outcome (P=0.30). A high NIHSS score was an independent risk factor for poor outcome (P<0.01), while older age showed only a trend toward adverse prognosis (P=0.20). Prolonged OPT was significantly associated with poor outcome (per 1-hour delay, OR≈0.61, P= 0.04). The results of the sensitivity analysis (considering only patients with OPT≤6 hours) were consistent with the main analysis. Conclusion: In this retrospective cohort, there were no statistically significant differences in functional outcome and mortality between the bridging therapy group and the direct EVT group in patients with PC-LVO. Future large-sample randomized studies are needed to further validate the role of bridging therapy in posterior circulation stroke.