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Background: There may be a delay in or a poor outcome of endovascular treatment (EVT) among acute ischemic stroke (AIS) patients with large-vessel occlusion (LVO) during off-hours. By using a prospective, nationwide registry, we compared the workflow intervals and radiological/clinical outcomes between patients with acute LVO treated with EVT presenting during off- and on-hours.Methods: We analyzed prospectively collected Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) data. Patients presenting during off-hours were defined as those presenting to the emergency department from Monday to Friday between 17:30 and 08:00, on weekends (from 17:30 on Friday to 08:00 on Monday), and on national holidays. We used logistic regression models with adjustment for potential confounders to determine independent associations between the time of presentation and outcomes.Results: Among 1,788 patients, 1,079 (60.3%) presented during off-hours. The median onset-to-door time and onset-to-reperfusion time were significantly longer during off-hours than during on-hours (165 vs. 125 min, P = 0.002 and 410 vs. 392 min, P = 0.027). The rates of successful reperfusion and symptomatic intracranial hemorrhage were similar in both groups. The adjusted odds ratio (OR) for the 90-day modified Rankin Scale score was 0.892 [95% confidence interval (CI), 0.748–1.064]. The adjusted OR for the occurrence of functional independence was 0.892 (95% CI, 0.724–1.098), and the adjusted OR for mortality was 1.214 (95% CI, 0.919–1.603).Conclusions: Off-hours presentation in the nationwide real-world registry was associated with a delay in the visit and reperfusion time of EVT in patients with AIS. However, this delay was not associated with worse functional outcomes or higher mortality rates.Clinical Trial Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939.