Background: In the United States there has been no national stroke registry that tracks emergency intra-hospital processes of care and 90-day clinical outcomes for both IV tPA and/or emergency endovascular (IA) stroke treatment. The Joint Commission and other regulatory agencies now mandate use of a national stroke registry based upon concurring recommendations from the Brain Attack Coalition, the American Stroke Association, and the international Multisociety Quality Improvement Guidelines. (online JVIR, Jan 29, 2013) Methods and Results: A custom software development company was employed to create a dedicated on-line national registry for tracking hospital processes and performance trends, and that could perform instant complex multifactorial analyses of clinical outcomes (90-day modified Rankin Score (mRS) based upon numerous patient-specific characteristics. Extensive physician interaction with the software company over a period of years allowed construction of a complex analytical machine with a built-in logic chain for numerous clinical process steps resulting in automatic error detection of out-of-range or impossible answers. The simple self-prompting point and click data entry system typically requires 10 minutes for each stroke alert, 20 minutes for each IV tPA case, and 45 minutes for all aspects of an IA stroke case. INSTOR is a HIPAA compliant, point-and-click national registry that tracks processes-of-care as well as clinical outcomes for both IV tPA and endovascular therapies. All major data points are presented as “site” vs. “All”, with “All” being an anonymous aggregate of data from all participating sites. Conclusions: INSTOR presents instant online graphical and numerical results including “door to CT”, “door to IV tPA”, “time for return of laboratory results” and “time to angiography”, etc. Process trends are presented with graphed monthly median data points overlain by a logistic regression trend line. The computerized multisite database also has the capability of automatically sending text massage or email reminders to designated recipients for follow-up events such as discharge information or 90-day mRS. INSTOR instantly performs complex multifactorial analyses of numerous measures of clinical outcomes for both IV tPA and endovascular stroke interventions and presents this data in standard stacked bar chart form. Outcomes data results include: all ASA Metrics for ischemic stroke, 90-day mRS for IV tPA, IV + IA, and IA treatment alone, and all data points mandated by the international Multisociety Quality Improvement Guidelines. 90-day clinical Outcomes are also analyzed based upon baseline clinical factors such as original NIHSS, vascular occlusion site, and comorbidities such as atrial fibrillation, diabetes, hypertension, and age.