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Introduction/Purpose Endovascular thrombectomy (EVT) eligibility has expanded following large-core infarct trials and the 2026 AHA/ASA guideline, which now includes class I recommendations for anterior circulation large-core strokes up to 24 hours and basilar artery occlusions. As more patients become EVT candidates, identifying subgroups at risk for systematic underuse becomes critical. Psychiatric comorbidity has been linked to lower intravenous thrombolysis (IVT) rates, but no study has examined whether this disparity extends to EVT or whether PTSD whose core features of avoidance, dissociation, and hyperarousal can confound hyperacute stroke evaluation carries a distinct association. We examined associations between PTSD and co-occurring psychiatric comorbidity and the receipt of IVT and EVT in a nationally representative sample of acute ischemic stroke (AIS) hospitalizations.Materials and Methods We identified AIS discharges (ICD-10-CM I63.x) in the NIS 2019-2022. Psychiatric comorbidity was classified into four mutually exclusive groups: no psychiatric diagnosis (reference), other psychiatric diagnoses without PTSD, PTSD only, and PTSD with co-occurring psychiatric diagnoses (PTSD+other). IVT and EVT were identified by ICD-10-PCS codes. A territory-based large-vessel occlusion (LVO) proxy was constructed from stroke subtype codes (I63.0-I63.5). Survey-weighted logistic regression used year-unique design identifiers per HCUP pooling guidance. The primary model included all discharges, adjusting for demographics, Elixhauser comorbidities, hospital characteristics, and transfer status. Sensitivity analyses additionally controlled for NIHSS category (62.3% coded) and the LVO proxy.Results Among 418,612 AIS discharges (weighted N = 2,093,059), 14,865 (3.6%) had PTSD: 600 PTSD only and 11,865 PTSD+other (weighted). Overall, 13.1% received IVT and 7.6% received EVT. EVT: In the full-cohort model, PTSD+other was associated with significantly lower EVT odds (aOR 0.74; 95% CI 0.60-0.91; P = .005). After adjustment for NIHSS and the LVO proxy, this deficit persisted (aOR 0.69; 95% CI 0.54-0.88; P = .003). In the LVO-restricted sensitivity analysis, PTSD+other remained significant (aOR 0.67; 95% CI 0.52-0.85; P = .001).IVT Associations with IVT were smaller and more heterogeneous. Other psychiatric diagnoses without PTSD showed a modest IVT deficit (aOR 0.93; 95% CI 0.90-0.96; P < .001), while PTSD+other showed a similar direction but did not consistently reach significance across sensitivity models.The PTSD+other group was younger (mean 61.4 vs 70.2 years), predominantly male (79.5%), and enriched for substance use, depression, and anxiety. NIHSS coding rates were similar across psychiatric groups (60.9-63.5%), indicating non-differential selection.Conclusion In this nationally representative analysis of over 400,000 AIS hospitalizations, PTSD with co-occurring psychiatric diagnoses was independently associated with 31% lower EVT odds after adjustment for stroke severity and LVO status. This EVT-specific disparity persisted across sensitivity specifications including restriction to LVO patients. As thrombectomy eligibility expands under the 2026 AHA/ASA guideline, the PTSD+other phenotype represents a potentially widening barrier to equitable EVT access. These findings support development of triage protocols that mitigate diagnostic overshadowing in psychiatrically complex stroke presentations.Disclosures D. Vaishnav: None. T. Vadset: None.