Abstract Body: Introduction: The evolving landscape of acute ischemic stroke (AIS) demands knowledge of the changing demographics, treatment status and stroke outcomes. Methods: Temporal trends in characteristics, presentation, guideline recommended therapies (defect free care-DFC), in-hospital mortality, and functional outcomes of AIS patients enrolled in GWTG-S, Florida Stroke Registry (FSR) were evaluated from 2012 to 2023 using multinomial temporal model adjusting for age, sex, race, severity, pre-morbid disability, time from onset to arrival and DFC. Results: A total of 311,471 AIS patients with available mortality data were included (mean age 70.7(14.2), 48.8% female, 63.6% white, 18.8% black, 13.5% Hispanic). The median onset to arrival (OTA) was 232 min [IQR=651], median NIHSS was 4 (1,9), 59% arrived by EMS, 15.3% received reperfusion therapies (11.8% IV thrombolysis, 5.4% thrombectomy, 1.9% both), 68.4% received DFC. Temporal analysis showed a trend for diminishing age (73 to 71yrs), increased median OTA (192 to 299 min), decreased median NIHSS (4 to 3), increased receipt of reperfusion therapies (9% to 17%) and DFC (18% to 83%) through the study period (p for trend <0.001). In-hospital mortality occurred in 3.2% (median presenting NIHSS 17 (8,24)), 6.2% were discharged to hospice, discharged mRS 4-5 was 40.1%, mRS 2-3 was 22.3% and mRS 0-1 was 34.4%. Multinomial adjusted temporal analysis showed stable in-hospital mortality over time (OR=1.01, 0.99,1.01, p=0.95), but increased rates of hospice admission (OR=1.036 [1.03, 1.04], p<.0001) and discharge mRS 4-5 (OR=1.01 (1.00, 1.01) P<0.0001). Conclusion: This real-world data shows a decline in age and stroke severity, and a rise in utilization of reperfusion and guideline recommended therapies in AIS patients over time. Despite improved stroke care and a stable mortality rate, a temporal increase in significant disability at discharge is observed. This data suggests an expected rise in functional burden from AIS.