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Background: Mechanical thrombectomy has become standard of care for emergent large vessel occlusive (ELVO) stroke. Estimates of incidence for thrombectomy eligibility vary significantly. NIH Stroke Scale (NIHSS) of 9 or greater is highly predictive of large vessel occlusion. Using our Kentucky Appalachian Stroke Registry (KApSR), we evaluated regional trends in stroke admissions with NIHSS of 10 or more to determine effects and needs in thrombectomy utilization.Methods: Using the KApSR database that captures patients throughout the Appalachian region in our stroke network, we evaluated patients admitted with ischemic stroke with NIHSS > 9 anytime during admission. We recorded demographics, comorbidities, treatment (thrombectomy, decompressive craniectomy), and county of origin. Change in NIHSS from admission to discharge was measured as an indicator of inpatient outcome. Summary statistics and analyses were performed on SPSS; p<0.05 was significant.Results: From 2010 to 2016, 2250 patients were included; 132 (5.9%) underwent thrombectomy. 66.8% were admitted with NIHSS > 9. Annual utilization of thrombectomy increased over time from 0.8% in 2010 to 10.6% in 2016. When thrombectomy was considered, median change in NIHSS was -2 (IQR 8) in patients without thrombectomy versus -5 (IQR 12) in patients who underwent thrombectomy; the difference was significant (p<0.001). Furthermore, while the median change in NIHSS remained stable for non-thrombectomy patients, it improved over time for thrombectomy patients (Figure 1).Conclusion: Among patients with significant inpatient ischemic stroke, a majority present with NIHSS greater than 9. While thrombectomy has become more common, it was only utilized in 10.6% of patients in 2016. Furthermore, patients who underwent thrombectomy has significant inpatient clinical improvement compared to those that did not. Thus, further efforts are necessary to maximize the use of thrombectomy when appropriate.