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Introduction: Studies have shown that 4-17% of acute ischemic strokes (AIS) occur in the patients hospitalized for another reason.We present one of the largest single center data in the US on quality of care and outcome of in-hospital strokes from our large volume comprehensive stroke center at Buffalo general Hospital, Buffalo, NY.Methods: In a retrospective study, all patients who suffered an AIS after being admitted for another reason to our center from January 2006 till June 2015 were included in the study. Variables studied included demographics, comorbid illness, NIHSS on admission, clinical presentation and NIHSS at the time of stroke, location of infarction on brain imaging, location of the patient while stroke occurred, treatment undertaken, quality of care measures and outcome on discharge using modified Rankin Scale( mRS).Results: We found 53 patients who suffered AIS proven on brain imaging after being hospitalized for another reason in the study period. Twenty seven were females (51 %). Mean age was 69.4 (±13.1). Mean NIHSS on admission was 0. Mean NIHSS at the time of stroke was 10.1 (±9.72). Mean Time of symptom recognition to neuroimaging was 7 hours (±14.4 hours). Only in 4 patients (7.5%) head CT scans were done within 25 minutes from symptom recognition. Forty two (79%) underwent brain imaging within 6 hours of symptom recognition, out of them 11(26%) received intravenous thrombolysis (IVT) within the first 4.5 hours and 7 (17%) underwent intra-arterial thrombolysis (IAT). The patients admitted in the emergency room(ER) for other reasons or intensive care units(ICU) had more chance of being eligible for IVT or/and IAT from timing stand point compared to the patients admitted to the regular floors ( 44 % vs 25% ) . In 15 patients (28%), there was a delay in symptom recognition or treatment due to diagnosis uncertainty. The mean MRS on discharge 2.37 (± 2.16) with a mortality rate of 13%.Conclusion: Due to logistical problems, only a small number of patients with in-hospital strokes received brain imaging within the time window recommended by ASA/AHA guideline. We need to improve awareness of stroke symptoms among medical staff including nurses and non-neurology physicians which might leads to a more timely initiation of treatment and better outcome.