Objective To understand stroke risk factors, status of stroke care, and opportunities for improvement as China and India develop national strategies to address their disproportionate and growing burden of stroke. Methods We compared stroke risk factors, acute management, adherence to quality performance measures, and clinical outcomes among hospitalized ischemic stroke patients using data from the Indo-US Collaborative Stroke Project (IUCSP) and China National Stroke Registry-II (CNSR-II). The IUCSP included 5 academic stroke centers from different geographic regions (n = 2,066). For comparison, the CNSR-II dataset was restricted to 31 academic hospitals among 219 participating sites from 31 provinces (n = 1,973). Results Indian patients were significantly younger, had health insurance less often, and had significantly different risk factors (more often diabetes mellitus, dyslipidemia, and coronary heart disease; less often prior stroke, hypertension, atrial fibrillation, and smoking). Hospitalized Indian patients had greater stroke severity (median NIH Stroke Scale score 10 vs 4), higher rates of IV thrombolysis within 3 hours (7.5% vs 2.4%), greater in-hospital mortality (7.9% vs 1.2%), and worse outcome (3-month modified Rankin Scale score 0-2, 49.3% vs 78.1%) (all p < 0.001). The poorer clinical outcomes were attributable mainly to greater stroke severity in IUCSP patients. Chinese patients more often received antithrombotics, stroke education, and dysphagia screening during hospitalization. Conclusion These data provide insights into the status of ischemic stroke care in academic urban centers within 2 large Asian countries. Further research is needed to determine whether these patterns are representative of care across the countries, to explain differences in observed severity, and to drive improvements.