This retrospective cohort study analyzed electronic health records from the TriNetX Research Network, accessed in June 2025. Adult ischemic stroke patients (≥18 years, ICD-10: I63) with documented NIHSS scores (ICD-10: R29.7) between 2015 and 2025 were included. Patients were categorized by healthcare facility type (academic vs. non-academic). Propensity score matching (PSM) adjusted for demographics, comorbidities, NIHSS scores, social determinants of health, and medication use. Outcomes were assessed up to 90 days post-stroke.

Of 227,246 patients, 65.1% were treated at academic centers. Academic centers had higher proportions of younger, White, and Black patients. Academic centers also treated patients with more severe strokes. After matching (n=56,590 per group), academic centers demonstrated significantly higher rates of mortality (11.2% vs. 7.1%), MT (9.5% vs. 7.3%), ICH (13.4% vs. 9.8%), IV thrombolysis at different facilities (9.1% vs. 5.7%), readmissions (33.2% vs. 31.3%), ICU utilization (42.4% vs. 34.8%), and withdrawal of life supporting therapy (21.5% vs. 19.3%; all p<0.001). Conversely, academic centers had lower rates of IV thrombolysis (9.0% vs. 11.6%, p<0.001) and dependent functional status at discharge (13.8% vs. 14.5%, p<0.001), andemergency department (ED) utilization (9.1% vs. 9.7%, p=0.001). Subgroup analyses showed broadly consistent trends, with some variation in ICH, ED utilization, readmissions, and functional status showed some variation.