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Background: Stroke remains a significant global health problem and a major cause of mortality and long-term disability, disproportionately affecting low- and middle-income countries. In the Republic of North Macedonia, stroke represents a significant public health challenge, yet systematic data on prehospital stroke care are lacking. Aim: To conduct a comprehensive epidemiological analysis of stroke patients managed by the Emergency Medical Service in Skopje over a five-year period (2021–2025), including analysis of annual distribution, demographic characteristics, stroke types, and transport rates to hospital. Materials and Methods: This retrospective study analyzed data from the electronic database of the Emergency Medical Service – Skopje, including all patients diagnosed with stroke during 2021–2025. Variables analyzed included total number of stroke-related calls, patient sex and age, stroke type (acute first-ever versus recurrent strokes), and transport to hospital. Descriptive statistics and chi-square tests were used for data analysis. Results: During the study period, 6,966 stroke cases were documented, accounting for 5.8% of all emergency calls. The greatest proportion occurred in 2021 (6.5%), whereas the smallest proportion was observed in 2024 (5.2%). Females were significantly more represented than males (57.7% vs. 42.4%; p < 0.001). Age analysis showed that 88.0% of patients were over 60 years, 11.8% were aged 40–60 years, and only 0.27% were aged 20–40 years. Acute (first-ever) strokes accounted for 61.5% of cases, while recurrent strokes (re-ictus) constituted 38.5%. A significant trend of increasing acute cases was observed, from 55.9% in 2021 to 70.9% in 2025 (p < 0.001). The transport rate to hospital showed a continuous improvement, increasing from 57.0% in 2021 to 72.6% in 2025 (p < 0.001), with an overall transport rate of 62.6%. Conclusion: This first comprehensive prehospital stroke study in Skopje reveals a predominant burden among the elderly, particularly women, with a concerning high proportion of recurrent strokes (38.5%) indicating suboptimal secondary prevention. The significant improvement in hospital transport rates over the five-year period (from 57.0% to 72.6%) reflects progress in prehospital care, education, and protocols. However, 37.4% of patients remain non-transported, highlighting an area for further improvement. These findings provide baseline data for the development of evidence-based protocols and targeted prevention strategies to reduce stroke-related morbidity and mortality in North Macedonia.