Abstract Body: Introduction: Mechanical thrombectomy (MT) dramatically improves the outcome for patients with acute ischemic stroke due to large vessel occlusion (LVO). There are racial and socioeconomic disparities in access to MT. In addition, while thrombectomy-specific data are limited, there are clear urban-rural disparities in access to acute stroke care. Hypothesis: We hypothesized that in a rural state in which the Emergency Medical System (EMS) routes all suspected stroke patients to the nearest available stroke center of any level, there would be a significant association between rural LVO patient location and lower rates of MT. Methods: As part of an ongoing statewide stroke system implementation initiative, Stroke STAT, we prospectively collected data on patients presenting to EMS with suspected stroke due to LVO from 4/30/22 to 10/9/23. As of March, 2023, the Alabama acute stroke system included 10 centers performing thrombectomy (including Comprehensive Stroke Centers (Level 1) and Thrombectomy capable Stroke Centers (Level 2a) out of 81 hospitals in the stroke system. All thrombectomy performing hospitals are located in urban areas, as shown in the Figure. We collected zip and rural-urban commuting area (RUCA) codes of initial EMS contact, age, sex, ethnicity, race, initial NIHSS score, reperfusion treatment rates with thrombolysis or MT, and whether the patient was transferred from one hospital to another in the acute period (transferred). Differences were assessed using Chi-squared, t-test and the appropriate non-parametric methods at 0.05 significance. Results: There were 2,692 patients with suspected stroke due to LVO in the study period, including 1,921 with urban and 771 with rural point of initial EMS contact. There were 497 patients with LVO, including 293 (59%) who underwent MT. As shown in Table 1, there were no differences in rates of MT by age, sex, ethnicity, or race. As shown in Table 2, rural and urban patients had equal access to tPA, but rural patients were less likely to receive MT 80/179 (45%) vs. 213/318 (67%) (p<0.0001). Conclusions: In a large cohort from a rural state, we found that rural patients encountered by EMS with stroke due to large vessel occlusion have similar rates of treatment with thrombolytic therapy but significantly less access to mechanical thrombectomy compared to urban patients. Stroke systems of care need to evolve to improve rural access to mechanical thrombectomy.