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Introduction: Thrombectomy for acute ischemic stroke (AIS) is an important intervention, though the majority of eligible patients do not receive it. Drawing upon data from our high volume comprehensive stroke center, we identified barriers to recognizing patients with large vessel occlusion and subsequent impediments to treatment.Methods: This is a retrospective chart review of patients presenting with AIS within 24 hours to the 14 hospitals within the AHCS between January 2015 and December 2016. Demographic, National Institutes of Health Stroke Scale (NIHSS) score, vascular imaging, and thrombectomy data were collected and analyzed. Large vessel occlusion (LVO) involved the distal internal carotid artery (ICA), middle cerebral artery (M1), or basilar artery (BA).Results: Three thousand five hundred ninety- five AIS patients were identified. The median age was 61 years and 1863 (52%) were female. Two thousand one hundred eighty-three patients presented within 24 hours (61%): 1105 ≤ 6 hours. More than one third of AIS patients (773) did not have acute intracranial vascular imaging. Of 1410 patients with vascular imaging, 171 patients (12 %) had LVO. The site of occlusion was: M1, 86 patients (50.3%); distal ICA, 51 (30%); and BA, 27 (16%). Only 75 LVO patients (44%) had acute stroke intervention of whom 57 (77%) had mechanical thrombectomy, additional intra-arterial thrombolysis was given in 14 (19%) and 4 (5%) had intra-arterial thrombolysis as monotherapy. Successful revascularization (mTICI 2b-3) was achieved in 53 patients (70%). The main reasons that LVO patients did not receive acute stroke intervention include: late onset or unknown onset in 32 (35%), large core infarction 25 (27%), rapid improving NIHSS in 6 (7%), and unclear reason in 25 (17%),Conclusion: There are several reasons that LVO is under recognized: a non neurologist often evaluates the patient in the ER first and they might not be familiar with stroke protocol guidelines; some LVO patients have an atypical presentation; and some patients refuse intervention. Based on our data, there is a need for continuing education of stroke care providers, particularly in this period of changing interventional guidelines.