Background <p>Telestroke improves access to stroke care in underserved areas but requires a high initial investment. Evidence on its cost-effectiveness is limited in developing countries. This study aims to evaluate the cost-effectiveness of treating acute ischemic stroke (AIS) patients with telestroke compared to non-telestroke in China.</p> Methods <p>A Markov model is developed to assess the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of telestroke compared with non-telestroke over a lifetime horizon. The model incorporates four treatment pathways (intravenous thrombolysis (IVT), endovascular therapy (EVT), bridging therapy, and conservative treatment) and symptomatic intracerebral hemorrhage (sICH). Health states are divided into independent (modified Rankin Scale(mRS) 0–2), dependent (mRS 3–5), or deceased (mRS 6). The model cycle length is 1 year. Both costs and QALYs are discounted at 3% annually. The willingness-to-pay (WTP) threshold is set at 3 × gross domestic product per capita (268,074 Chinese Yuan (CNY) or 38,042 United States Dollar (USD) per QALY in 2023).</p> Results <p>Compared to non-telestroke, telestroke increases costs by 18,020 CNY and adds 0.1142 QALYs, resulting in an ICER of 157,763 CNY (22,388 USD) per QALY in lifetime horizon. One-way sensitivity analyses reveal that ICER is most sensitive to the probability of patients being independent (mRS 0–2) after EVT. Probabilistic sensitivity analysis shows that telestroke is cost-effective in 86.59% of the 10,000 simulations.</p> Conclusions <p>Telestroke is cost-effective for AIS management in China, supporting its broader adoption.</p>