Background and aims: In high-income countries, stroke incidence in the 21st century has increased or stagnated in young and middle-aged individuals. Assessing temporal trends in post-stroke outcomes is necessary to understand the impact of these changes in incidence. Methods: Embase and MEDLINE were searched from 1 January 1970 to 30 October 2024. Studies were included if they reported case fatality, 1-year or 5-year mortality, or stroke recurrence in patients aged up to 65 years. For studies reporting outcomes across multiple time periods, risk ratios (RRs) were calculated comparing the earliest and latest periods and pooled using inverse-variance random-effects models. The annualized change in the RR for case fatality was estimated using meta-regression. Results: Twenty-two studies reported case fatality across 28 populations after all strokes or ischemic stroke and intracerebral hemorrhage (14 population-based and 14 based on routinely collected data). The median (interquartile range (IQR)) duration between compared time points was 9 (7–13.3) years. Case fatality decreased over time (RR = 0.74, 95% confidence interval (CI) = 0.68–0.81), corresponding to a mean annual relative reduction of 3.2% (95% CI = 1.4–5.0). Results were consistent by age, sex, study design, geographical region, and stroke subtype (six studies; ischemic stroke: RR = 0.79, 95% CI = 0.75–0.83; intracerebral hemorrhage: RR = 0.77, 95% CI = 0.69–0.86). Trends were similar before and after 2000, with continued improvement after 2010 compared with 2000–2009 (six studies; RR = 0.70, 95% CI = 0.63–0.77). In addition, mortality decreased at 1 year (five studies; RR = 0.68, 95% CI = 0.52–0.87) and at 5 years after stroke (four studies; RR = 0.65, 95% CI = 0.45–0.95). In contrast, the 1-year cumulative incidence of recurrent stroke was unchanged after 2000 (three studies; RR = 1.04, 95% CI = 0.78–1.39). Conclusion: Early case fatality and long-term survival after stroke have progressively improved since the 1970s in high-income countries among young and middle-aged individuals, but stroke recurrence rates may have stagnated in the past two decades.