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Introduction: Stroke patients can experience neurological change in the prehospital setting. We sought to identify factors associated with prehospital neurologic deterioration.Methods: Among the Greater Cincinnati/Northern Kentucky region (pop. ~1.3 million), we screened all 15 local hospitals’ admissions from 2010 for acute stroke, and included patients with age ≥20 and complete EMS records. Glasgow Coma Scale (GCS) at hospital arrival was compared with GCS evaluated by EMS, with decrease ≥2 points considered neurologic deterioration. Data obtained included age, sex, race, medical history, antiplatelet or anticoagulant use, stroke subtype [ischemic (IS), ICH, or SAH] and IS subtype (e.g., small vessel, large vessel, cardioembolic), seizure at onset, time from symptom onset to EMS arrival, time from EMS to hospital arrival, blood pressure and serum glucose on EMS arrival, and EMS level of training. Univariate analysis was completed using Wilcoxon rank sum test for continuous measures and chi-square or Fisher’s exact test for categorical measures. Multivariate analysis was completed on variables with p ≤ 0.20 in the univariate analysis.Results: Of 2708 total stroke patients, 1097 (870 IS, 176 ICH, 51 SAH) had EMS records (median [IQR] age 74 [61, 83] years; 56% female; 21% black). Onset to EMS arrival was ≤4.5 hours for 508 cases (46%), and median time from EMS to hospital arrival was 26 minutes. Neurological deterioration occurred in 129 cases (12%), including 9.1% of IS and 22% of ICH/SAH. In multivariate analysis, black race, atrial fibrillation, ICH or SAH subtype, and ALS transport were associated with neurological deterioration.Conclusion: Atrial fibrillation may predict prehospital deterioration in stroke, and preferential transport of patients with acute worsening to centers capable of managing hemorrhagic stroke may be justifiable. Further studies are needed to identify why race is associated with deterioration and potential areas of intervention.