ObjectiveTo evaluate the efficacy and safety of anisodine hydrobromide injection in patients with acute ischemic stroke in a real-world clinical setting.DesignMulticenter, real-world observational cohort study conducted from April 2018 to December 2021 with 90-day follow-up. Multivariable logistic regression and inverse probability of treatment weighting (IPTW) were applied.ParticipantsA total of 4,179 patients aged ≥18 years with acute ischemic stroke admitted within 30 days of onset were included; 2,120 received anisodine hydrobromide and 2,059 received best medical treatment.ExposureIntravenous anisodine hydrobromide injection administered as part of routine clinical care.OutcomesThe primary outcome was unfavorable functional outcome (modified Rankin Scale [mRS] 3–6) at 90 days. Secondary outcomes included overall mRS distribution, changes in National Institutes of Health Stroke Scale (NIHSS) scores, hemorrhagic transformation, and 90-day mortality or recurrent stroke.ResultsUnfavorable functional outcome occurred in 14.3% (282/2,120) of the anisodine group versus 20.6% (396/2059) of controls (adjusted OR, 0.63; 95% CI, 0.53–0.74). IPTW analysis confirmed the result (OR, 0.64; 95% CI, 0.51–0.80). The anisodine group had a more favorable mRS distribution (OR, 0.68; 95% CI, 0.61–0.77) and greater NIHSS improvement (mean ΔNIHSS difference = −0.61; 95% CI, −0.79 to −0.43). Hemorrhagic transformation, mortality, and recurrent stroke did not differ significantly between groups.ConclusionIn this large multicenter cohort conducted in China, anisodine hydrobromide showed a potential association with improved 90-day functional outcomes, with no clear increase in adverse events among patients with acute ischemic stroke.Clinical Trial Registrationhttps://www.chictr.org.cn/, identifier ChiCTR1900027517.