Acute stroke care has evolved significantly over the past decade, driven by advancements in intravenous thrombolysis (IVT) [1] and endovascular thrombectomy (EVT) [2,3] for ischemic stroke (IS), comprehensive bundle care [4,5] and surgical management [6] for intracerebral hemorrhage (ICH), and coil embolization [7] for ruptured aneurysmal subarachnoid hemorrhage (SAH). While multiple randomized clinical trials have established the efficacy of these interventions, there is a pressing need for detailed analyses of real-world secular trends through nationwide reports to evaluate the actual impact and sustainability of these advancements.

However, existing nationwide studies often face methodological constraints that limit their clinical utility. Registry-based reports frequently rely on voluntary participation, which may lead to selection bias by excluding smaller or lower-performing facilities. Conversely, analyses based solely on administrative data often lack the clinical depth necessary to capture nuanced management metrics beyond mortality or basic hospital volume [8,9]. Furthermore, most existing nationwide studies focus exclusively on IS, providing a fragmented view of the overall stroke care landscape that neglects the distinct management shifts in ICH and SAH [10,11].

South Korea presents a unique clinical landscape due to its exceptionally rapid transition into a super-aging society, which places unprecedented pressure on the national stroke care system [12]. To address the limitations of prior research, this study utilizes the Acute Stroke Quality Assessment Program (ASQAP), a mandatory nationwide audit program evaluating inpatient care for nearly all acute stroke cases treated in general and tertiary hospitals across the country [13]. By integrating these mandatory clinical records with national insurance claims and the gold-standard resident registration system for mortality outcomes, we have established a robust longitudinal database with unparalleled representativeness and clinical granularity.

In this study, we sought to determine whether a decade (2013-2023) of systemic and clinical advancements has translated into sustained improvements in stroke outcomes across the full spectrum of stroke subtypes, including IS, ICH, and SAH. By evaluating the longitudinal evolution of management patterns—from prehospital metrics to advanced pharmacological and surgical interventions—this research aims to identify persistent challenges and assess the resilience of the national stroke care system in an era of rapid demographic change.

This study, utilizing a mandatory nationwide audit program, provides a comprehensive 10-year panorama of acute stroke care and outcomes in South Korea. Over the decade, we observed a substantial change in stroke management, characterized by the rapid adoption of endovascular therapies, a near-complete transition to NOACs, and a definitive shift toward minimally invasive interventions for SAH. However, our analysis also identified critical systemic bottlenecks, particularly a persistent prehospital delay and a concerning U-shaped reversal in adjusted mortality following the COVID-19 pandemic.

The unexplained discrepancy between ambulance use and arrival time remains one of the most critical challenges identified in this study. While ambulance utilization significantly increased across all stroke subtypes and direct routing to specialized stroke centers reached over 78.2%, the proportion of patients arriving within the 3-hour golden window remained disappointingly stagnant. This disconnect suggests that improving prehospital care requires more than just increasing public awareness or physical infrastructure. It highlights potential structural deficiencies within the current Emergency Medical Service (EMS) system, where prehospital triage and initial response protocols may not be sufficiently optimized for rapid stroke identification and dispatch. To bridge this gap, future research and policymaking should prioritize linking ASQAP data with EMS-specific databases. Such data linkage would allow for the granulation of prehospital time into “onset-to-first medical contact (FMC)” and “FMC-to-hospital arrival,” enabling targeted interventions to reduce systemic delays [16].

In the management of IS, the surge in EVT utilization—particularlyIn the management of IS, the surge in EVT utilization—particularly reaching 41.1% in severe cases—represents the most dynamic clinical change. This reflects the prompt integration of landmark trial evidence into real-world practice [17,18]. Interestingly, while the efficiency of hyperacute care remains high with 85% of patients achieving DTN time ≤60 minutes, this figure has plateaued. This “ceiling effect” indicates that most participating hospitals have already reached a high level of performance, yet further reduction in DTN time may require more advanced systemic interventions, such as pre-notification systems [19] or mobile stroke units [20]. The stabilization of IVT rates around 6.0% after 2014, despite the EVT surge, suggests a paradigm shift where clinical decision-making is increasingly tailored toward large vessel occlusion management, potentially prioritized over traditional thrombolysis in eligible cases [21]. In addition to EVT expansion, several other factors may have contributed to the IVT plateau. The 2013 American Heart Association/American Stroke Association guidelines [22] and the contemporaneous Korean Stroke Society guidelines extended IVT eligibility from 3 to 4.5 hours after symptom onset [23], which likely contributed to the initial increase in IVT utilization observed in 2014 (8.4%). However, because patients aged >80 years were excluded from the European Cooperative Acute Stroke Study III trial [24] that informed these guidelines, national reimbursement coverage for IVT in this age group remained restricted, potentially explaining the marked decline in IVT use among patients aged ≥80 years from 6.0% (2014) to 0.7% (2018). Following a revision of the HIRA reimbursement criteria in 2018 that removed this age restriction, IVT rates in patients aged ≥80 years rebounded to 4.8% (2020/2021) and 5.4% (2022/2023). Despite this recovery in the elderly subgroup, the overall national IVT rate remained stable at approximately 6%, reflecting a multifactorial equilibrium between expanding EVT indications, demographic aging, and evolving reimbursement policies.

The pharmacological landscape has been equally transformative, marked by near-universal statin prescriptions, the dominance of NOACs, and an increasing reliance on dual antiplatelet therapy (DAPT). Statin utilization increased to 92.1%, becoming a non-negotiable standard of care [25,26]. NOAC utilization skyrocketed to 78.4%, with apixaban and edoxaban emerging as the preferred agents, a trend that mirrors global shifts toward more patient-friendly and effective anticoagulation [26,27]. Furthermore, the significant rise in DAPT use at discharge (55.4% to 67.2%) demonstrates the rapid real-world implementation of recent evidence supporting its efficacy in minor stroke and transient ischemic attack [28,29]. These trends demonstrate that Korean clinicians are highly responsive to evidence-based guidelines, leading to a high degree of pharmacological optimization across the nation.

A key success story is the management of SAH, which was the only subtype to demonstrate a significant decline in crude mortality. This improvement is inextricably tied to the transition from surgical clipping to endovascular coiling—reaching 63.4%— and the increased focus on prophylactic management of unruptured aneurysms [30]. The declining proportion of SAH among all strokes further supports the success of nationwide screening and preventive coiling programs in reducing the incidence of aneurysmal rupture [31]. In contrast, management for ICH remained largely stable, though the emerging role of minimally invasive hematoma evacuation may disrupt this clinical equilibrium in the near future [32].

The most concerning finding is the non-linear “U-shaped” trend in adjusted mortality, with rates reaching a nadir in 2018 followed by a significant uptick after 2020. This reversal suggests that the progress made in the first half of the decade was offset by the combined impact of an exponentially aging population and the systemic disruptions of the COVID-19 pandemic [33]. Although the temporal increase coincided with the COVID-19 pandemic period, no pandemic-specific or system-level variables could be included in the analysis, precluding causal inference. Other plausible explanations include the rapid growth of the very elderly population and increasing frailty and comorbidity burden. The doubling of the “old-old” (≥85 years) demographic places unprecedented strain on post-acute care and rehabilitation services, which may have been further affected during the pandemic period. These findings serve as a critical warning, highlighting the urgent need for healthcare systems to build robust resilience and sustainable care models that can withstand global crises while managing the complexities of a super-aging society. Further studies incorporating healthcare system capacity and pandemic-related indicators are needed to clarify the mechanisms underlying this temporal association.

While this study benefits from a mandatory nationwide dataset with virtually no loss to follow-up, several limitations must be acknowledged. The exclusion of low-volume facilities and potential seasonal effects of the audit periods may affect the generalizability of certain findings. Moreover, the results reflect a stroke care system with distinctive organizational features, including universal health coverage and centralized quality monitoring. Despite these system-specific characteristics, several observed trends—such as EVT expansion and increased NOAC use—are consistent with international experience and may offer useful insights for other rapidly aging societies, particularly regarding the value of sustained national quality monitoring programs and policy-level reimbursement alignment in translating clinical evidence into real-world practice. Additionally, the reliance on claims data for certain interventions and the lack of detailed clinical history (e.g., specific risk factors) may limit the depth of the causal analysis. Although we performed additional adjustment for CCI score to account for baseline comorbidity burden, residual confounding related to premorbid functional status, frailty, or treatment limitation decisions—particularly among the rapidly increasing very elderly population—cannot be fully excluded. Nevertheless, the unparalleled scale and clinical granularity of the ASQAP database provide robust evidence for the evolving landscape of stroke care in Korea.

Over the past decade, inpatient acute stroke management in South Korea has undergone substantial evolution, characterized by the rapid integration of endovascular thrombectomy for severe IS, a definitive transition to endovascular coiling for SAH, and highly optimized pharmacological care featuring near-universal statin use and the widespread adoption of NOACs and dual antiplatelet therapy. These advancements reflect a highly responsive healthcare system that successfully translates emerging clinical evidence into real-world practice.

However, notable challenges remain regarding the sustainability of these clinical gains. First, the “unexplained discrepancy between ambulance use and arrival time”—where increased emergency transport has not yet translated into improved golden-hour arrival rates—highlights important bottlenecks in the prehospital care continuum. Future policies must move beyond simply increasing ambulance utilization to focus on enhancing EMS triage protocols and optimizing hospital-EMS data linkage to minimize systemic delays.

Furthermore, the non-linear, U-shaped reversal in adjusted mortality following the COVID-19 pandemic highlights the potential vulnerability of the stroke care system in a rapidly superaging society. This reversal underscores the importance of building robust healthcare resilience. To sustain the progress made in stroke outcomes, it is essential to develop scalable care models that can address the complex needs of the oldest-old population while maintaining operational integrity during global health crises.