Effective preventive strategies are increasingly needed to reduce the burden associated with acute cerebrovascular events. Assessment of secular trends in stroke patients helps to identify aspects susceptible to improvement in the care of these patients. The aim of this study was to determine changes in clinical characteristics and early outcome of very old patients (aged 85 years or above) with acute stroke attended in our hospital between the period of 1986 and 2009. Data from very old patients with first-ever stroke (n = 764) included in the Sagrat Cor Hospital of Barcelona Stroke Registry were analyzed. Changes during the periods of 1986-1992, 1993-1998, 1999-2004 and 2005-2009 were compared. A statistically significant increase (P < 0.001) in the age of patients (87.9 years in 1986-1992 vs 88.9 years in 1999-2004) was observed. The percentage of patients with ischemic heart disease increased from 4.7% to 19.5% (P = 0.001). Also there was an increase in the percentage of patients with atrial fibrillation (25.2% to 35.6%), lacunar infarcts (11% to 15.7%) and cardioembolic stroke (16.5% to 35.4%). The use of echocardiography also increased significantly during the study period. The in-hospital mortality decreased from 29.1% to 15.5% (P = 0.011), length of hospital stay from 21 to 13.4 days (P = 0.001) and prolonged hospital stay (> 12 days) from 55.1% to 35.8% (P = 0.002). Acute stroke in very old patients, in contrast to younger stroke patients continues to be a severe subtype of stroke with high risk of death in the immediate post-stroke phase (20.3%) and low probability of full neurological recovery at the time of hospital discharge (9%). Very old patients showed a poorer outcome compared with acute stroke patients younger than 85 years of age. Significant changes over a 24-year period included an increase in patients with ischemic heart disease, atrial fibrillation and lacunar and cardioembolic stroke, whereas the in-hospital mortality and the length of hospital stay decreased.