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Introduction: Rapid evaluation and treatment are critical for improving outcomes of acute ischemic stroke patients. Arrival by ambulance is associated with more rapid imaging and tPA administration. Predictors of arrival by ambulance have not been well described.Hypothesis: Ischemic stroke patients with increased stroke severity are more likely to arrive to the hospital by ambulance.Methods: Prospective study of all ischemic stroke patients presenting to Massachusetts hospitals participating in the Coverdell Registry from 2005-13 (60 of the states’ 70 hospitals license to receive stroke patients). Logistic regression analysis identified predictors of ambulance use, accounting for clustering by hospital.Results: Among 54,164 acute ischemic stroke patients in the sample, 60.2% (n=32,622) arrived by ambulance. Among the 29,236 patients in whom NIHSS was documented, 59.5% (n=17,380) arrived by ambulance. In bivariate analysis, patients arriving by ambulance had higher NIHSS (mean 8.3 versus 4.5, p<0.001). In logistic regression analysis adjusting for patient characteristics and clustering within hospital, increased age, Medicaid insurance, history of atrial fibrillation/flutter, previous stroke, presentation from another healthcare facility, and increased stroke severity remained predictors of arrival by ambulance (Table). Ambulance arrival was less likely among Asian patients, those with stroke onset after hospital arrival, and later year of presentation.Conclusions: While patients with increased stroke severity are more likely to present via EMS, the use of ambulance transport by stroke patients decreased significantly over time. Widespread public education efforts are still needed to stress the importance of ambulance use for suspected stroke symptoms.