The study analyzed 820 ischemic stroke patients in three Saudi hospitals from March 2020 to March 2021, resulting in a propensity score matching (2:1) cohort of 327 patients (218 without COVID-19 and 109 with COVID-19), adjusted for age, sex, smoking, diabetes, hypertension, and ischemic heart disease. Patients with COVID-19 had a significantly longer hospital stay (median 5 days vs. 3 days, p=0.044). They had higher rates of pneumonia (54.1% vs. 10.6%, p=0.001) and cognitive impairment (11.9% vs. 0.02%, p=0.002). In-hospital mortality was higher in patients with COVID-19 (23.9% vs. 10.1%, p=0.001). COVID-19 infection was associated with pneumonia (OR=10.88; 95% CI: 5.36–22.08, p<0.001), cognitive impairment (OR=5.81; 95% CI: 1.87–18.00, p=0.002) and in-hospital death (OR=3.15; 95% CI: 1.53–5.79, p=0.001). COVID-19 independently worsens ischemic stroke outcomes even after adjusting for risk factors. The findings suggest the need for more intensive monitoring of breathing and neurological status in these patients.