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Background: Studies of neurologic deterioration in stroke have primarily focused on the acute period 24 hours after arrival. We sought to determine whether prehospital/early ED hyper-acute deterioration portends subsequent deterioration in the 24 hour acute period, as well as other prehospital factors that may predict subsequent deterioration.Methods: All subjects were enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial. Hyper-acute neurologic deterioration was defined as Glasgow Coma Scale (GCS) decreasing ≥2 points from paramedic to ED evaluation, acute neurologic deterioration was defined as ≥4 point increase on the NIH Stroke Scale (NIHSS) from ED evaluation to 24 hours post-arrival. Other prehospital factors investigated included age, race, sex, WBC, serum glucose, arrival NIHSS, systolic blood pressure (SBP), body temperature, intracerebral hemorrhage (ICH), hypertension, smoking, diabetes, and previous stroke.Results: Of 1,643 patients, 184 (11.2%) experienced acute 24-hour deterioration. Among deteriorators; 45 % were female and mean age (SD) was 70 (±13.3) years. Median last-known-well time to assessments were: prehospital GCS 25 (IQR 15-46) mins, ED arrival GCS and NIHSS 149 (IQR 120-180) minutes and follow-up (24-hour) NIHSS 26 (IQR 18-30) hours. On multivariate analysis, hyper-acute deterioration increased the odds of subsequent acute neurological deterioration (OR = 2.24, p = 0.010, 95% CI 1.21-4.14). Other factors independently associated with acute 24-hour deterioration were ICH, arrival NIHSS, serum glucose level, SBP and body temperature (see Table 1).Conclusion: Hyper-acute deterioration is associated with increased odds of acute neurological deterioration in the subsequent 24-hour period.