Abstract Body: Objective: Most patients with concern for an acute stroke are transported by Emergency Medical Services (EMS) or a Mobile Stroke Unit (MSU) from community hospitals to a Comprehensive Stroke Center (CSC). Some receive intravenous thrombolysis (IVT) before transfer, while others are transferred for further evaluation and possibly treatment at the CSC. This project aims to assess whether the initial National Institute of Health Stroke Scale (NIHSS) score influences the likelihood of receiving IVT in a community setting, and the likelihood of transfer to the CSC, particularly for patients with low initial NIHSS scores.. Methods: We utilized Get with the Guidelines Data from a large academic hospital in Northeast Ohio including 21 regional hospitals and 1 CSC. An initial NIHSS score is assigned upon initial evaluation by by NIHSS-certified EMS and MSU first responders, or emergency department providers. Patient data was analyzed between January 1, 2022 and August 31, 2024 and stratified based on initial NIHSS score into very low (0-3), low (4-7), moderate (8-14) and high (≥ 15). The primary outcome group was patients who didn't receive IVT before transfer and received it after transfer to the CSC. Results: 326/359 (90.8%) of patients with very low NIHSS score (0-4) didn't receive IVT prior to transfer to CSC. Out of those patients, 6/326 (1.8%) received IVT upon arrival to the CSC. In those patients with low NIHSS score (4-7), 182/223 (81.6%) didn’t get IVT prior to transfer to CSC. Of those patients, 17/182 (9.3%) received IVT upon arrival to the CSC. Patients with moderate NIHSS score (8-14), 241/293 (82.25%) didn’t receive IVT prior to transfer to CSC. Out of those patients, 15/241 (6.22%) received IVT at the CSC. Finally, 300/387 (77.5%) of patients with high NIHSS score (>15) didn’t get IVT prior to transfer to CSC, and 5% (15/300) out of those patients received IVT at the CSC. Conclusion: A significant proportion of patients with low initial NIHSS scores (4-7) didn't receive IVT before transfer to a CSC, despite being deemed candidates for thrombolysis and receiving treatment after transfer. This raises the question of whether a low initial NIHSS score acts as a barrier to acute treatment in community settings. These preliminary findings highlight the need for prospective studies to better understand the prognostic impact of the initial NIHSS score, potentially improving assessment quality and educational efforts for optimal initial patient evaluation.