Data sources

This descriptive epidemiological study utilized multiple publicly available data sources. The primary dataset comprised the GBD 2021 study, accessed through the Institute for Health Metrics and Evaluation (IHME) Global Health Data Exchange (GHDx) [9]. The GBD study employs standardized methodology to estimate disease burden across 204 countries and territories using data from vital registration systems, verbal autopsy, surveillance, and published literature.

We extracted Saudi Arabia-specific estimates for three stroke categories defined by ICD-10 codes: ischemic stroke (I63), intracerebral hemorrhage (I61), and subarachnoid hemorrhage (I60). Variables included incident cases, deaths, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and DALYs. All estimates included a 95% UI generated through 1,000 draws from posterior distributions.

Supplementary data were obtained from the World Health Organization Global Health Observatory, the Saudi General Authority for Statistics (GASTAT) mortality databases (2017–2022), and systematic reviews indexed in PubMed and Scopus [10]. Hospital-based data from the Eastern Province Stroke Register and multicenter studies provided validation and additional granularity [11].

Study variables

The primary outcomes were age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), and age-standardized DALY rate per 100,000 population. Secondary outcomes included YLLs, YLDs, and case fatality rates. Age standardization employed the GBD 2019 global standard population. Demographic stratification included sex, age groups (< 50, 50–69, ≥ 70 years), and nationality, where available.

Risk factor attribution utilized GBD comparative risk assessment methodology, which quantifies the population-attributable fraction of stroke burden associated with modifiable risk factors, including hypertension, diabetes, high body mass index (BMI), dietary risks, tobacco use, and ambient air pollution [12].

Statistical analysis

Temporal trends were analyzed using Joinpoint regression to identify years when significant changes in trend slope occurred and to calculate annual percent change (APC) with 95% confidence intervals (CIs). Poisson regression models with robust standard errors examined associations between demographic factors and stroke metrics, reporting incidence rate ratios (IRRs) with 95% CI.

Autoregressive integrated moving average (ARIMA) models were employed for forecasting 2020–2030 trajectories based on 1990–2019 trends [6]. Regional comparisons utilized World Health Organization regional groupings (MENA, GCC) and Socio-demographic Index (SDI) quintiles.

Heterogeneity in regional incidence estimates was assessed using I² statistics from meta-analytic frameworks; the systematic review by Alqahtani and colleagues reported substantial heterogeneity (I² = 98.8%) across included studies [7]. Statistical significance was defined as p < 0.05 (two-sided). Analyses were conducted using R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria) and Stata version 17.0 (StataCorp LLC, College Station, TX).

Ethical considerations

This study involved secondary analysis of publicly available, de-identified aggregate data and did not require institutional review board approval. The GBD 2021 study has received ethical approval from the University of Washington Institutional Review Board (STUDY00009060). Data from GASTAT are collected under the Statistics Law and are publicly accessible in aggregate form. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [13]. No patient-level data were accessed, ensuring participant confidentiality and data protection.

Data availability statement

All data analyzed in this study are publicly available. GBD 2021 data are available from the IHME GHDx (https://ghdx.healthdata.org/gbd-results-tool). GASTAT mortality data are available at https://www.stats.gov.sa. WHO Global Health Observatory data are available at https://www.who.int/data/gho.

Stroke incidence and temporal trends

The pooled annual stroke incidence in Saudi Arabia was 29 per 100,000 population (95% CI: 15–47), derived from a meta-analysis of five eligible population-based studies [7]. Regional variation was substantial, ranging from 13.89 per 100,000 in Al-Madinah to 57.64 per 100,000 (95% CI: 57.3–57.9) in the Aseer region (Table 1). The high heterogeneity (I² = 98.8%) across regional estimates reflects differences in study methodology, case ascertainment practices, and population demographics rather than uniform geographic distribution of disease [7].

Temporal trend analysis revealed that ASIRs increased from 1990 to 2014, followed by a plateau through 2019. This pattern varied by stroke subtype: ischemic stroke showed a sustained increase from 1990 to 2014 before stabilizing; intracerebral hemorrhage increased from 2000 to 2012, then decreased through 2016; subarachnoid hemorrhage decreased from 1990 to 2002, remained stable until 2015, then showed a slight increase [6].

Sex-stratified analysis using Poisson regression demonstrated significantly higher ischemic stroke incidence in females compared to males (IRR: 1.21, 95% CI: 1.16–1.26, p < 0.001). Subarachnoid hemorrhage similarly showed female predominance (IRR: 1.35, 95% CI: 1.15–1.58, p < 0.001). No significant sex difference was observed for intracerebral hemorrhage (IRR: 1.01, 95% CI: 0.94–1.09, p = 0.800) [6].

Stroke subtype distribution

Intracerebral hemorrhage accounted for 10.6–21.4% of cases in the majority of published Saudi series, while subarachnoid hemorrhage was notably rare at 1.4–2.4% [7, 14]. The Eastern Province Registry documented ischemic stroke at 69%, intracerebral hemorrhage at 29.6%, and subarachnoid hemorrhage at 1.4% [11]. The higher ICH proportion reported in the Eastern Province Registry (29.6%) likely reflects referral bias toward neurosurgical intervention at that center.

Among ischemic stroke subtypes classified by TOAST criteria, large vessel disease (52%) and lacunar infarctions (21–24.2%) predominated. In young stroke patients (< 50 years), small vessel occlusion was most frequent (31.7%), followed by cardioembolism (19%) and cryptogenic stroke (19%) [15].

Mortality patterns

The age-standardized death rate from stroke in the MENA region was 87.7 per 100,000 (95% UI: 78.2–97.6) in 2019, with Saudi Arabia positioned among higher-burden countries within its SDI subgroup [2]. Stroke accounted for approximately 11.7% of total deaths in Saudi Arabia, representing the second leading cause after ischemic heart disease [4].

Temporal analysis demonstrated a 27.8% decrease in the MENA regionʼs age-standardized mortality from 1990 to 2019, while total stroke deaths in Saudi Arabia increased by 193.33% over the same period (from 480 to 1,408 deaths), reflecting population growth despite improving age-standardized rates (Table 2) [2]. The overall stroke case fatality rate in Saudi hospital-based studies was 27%, exceeding rates reported in other Middle Eastern countries [6]. Case fatality rates varied by setting: 30-day mortality ranged from 11.1–15%, while one-year mortality reached 26.9% [7].

In-hospital mortality in the Aseer region was 9.7% (121 of 1,249 hospitalized patients) [16]. The population-level in-hospital stroke mortality rate for that study catchment area was 5.58 per 100,000 per year.

Disability-adjusted life years

Saudi Arabia-specific age-standardized DALY rates showed a consistent decline over the study period. Analysis demonstrated that each passing year was associated with a decrease of 9.28 DALYs per 100,000 (95% CI: 6.31–12.26, p < 0.001) [6]. At the MENA regional level, the percentage change in age-standardized DALYs from 1990 to 2019 was –32.0% (95% UI: –39.1 to –23.3) [2].

YLLs contributed the majority of stroke DALYs, representing approximately 93% of the total burden in 2021. Analysis of smoking-attributable stroke burden in Saudi Arabia revealed that age-standardized DALYs decreased by 22.4% from 1990 to 2021, with an average APC of –0.85 (95% CI: –0.88 to –0.83) [17].

Despite improvements in age-standardized rates, Saudi Arabia demonstrated higher-than-expected stroke DALYs relative to its SDI level, suggesting an opportunity for improvement compared to countries with similar levels of socioeconomic development [2]. ARIMA forecasting models predicted a continued gradual increase in age-standardized incidence through 2030, while DALYs were projected to show a sustained decrease [6].

Risk factor attribution

Analysis of modifiable risk factors in Saudi stroke patients revealed a high prevalence of metabolic risk factors (Table 3). In the largest multicenter case-control study (n = 2,498), hypertension was present in 57.7% of stroke cases versus 31.8% of controls (adjusted OR: 2.12, 95% CI: 1.74–2.57). Diabetes mellitus affected 49.4% of cases versus 25.9% of controls (adjusted OR: 1.73, 95% CI: 1.41–2.21). Obesity (BMI ≥ 30) was documented in 42.0% of cases (adjusted OR: 1.95, 95% CI: 1.61–2.28), and hypercholesterolemia in 29.4% (adjusted OR: 1.64, 95% CI: 1.28–2.10) [18].

The GBD comparative risk assessment identified Saudi Arabia as having the highest proportion globally (6.89%) of stroke DALYs attributable to high fasting plasma glucose, reflecting the exceptionally high diabetes prevalence in the Kingdom [2]. High BMI emerged as the most important attributable risk factor in Saudi Arabia, Qatar, and the United Arab Emirates (UAE) among GCC nations.

Physical inactivity was highly prevalent (86.9%) among stroke cases. Regular exercise was associated with substantially lower stroke odds (adjusted OR: 0.12, 95% CI: 0.05–0.26) [18]. While this finding is directionally consistent with the broader literature on the protective role of physical activity in stroke prevention, the magnitude of this association and its wide CIs should be interpreted with caution, given that it derives from a single regional case-control study and may be subject to residual confounding or recall bias. Current smoking was prevalent at 10.3% among stroke cases but did not reach statistical significance as an independent risk factor (OR: 1.15, 95% CI: 0.88–1.50).

Treatment patterns and gaps

Critical gaps in acute stroke treatment were identified (Table 4). Intravenous thrombolysis (IV tPA) utilization remained extremely low at 1–3.6% of eligible ischemic stroke patients in urban Saudi centers [19]. By comparison, US national IV tPA utilization rates improved from approximately 6.5% in the mid-2000s to 8–10% nationally by 2013, with comprehensive stroke centers exceeding this threshold [19, 20]. The treatment gap between Saudi Arabia and international benchmarks is therefore wider than historical comparisons suggest.

Analysis of barriers to thrombolysis revealed that 77% of exclusions were attributable to delayed emergency department arrival beyond the treatment window. Anticoagulant use within 48 hours accounted for 34% of exclusions, while recent prior stroke (7%) and uncontrolled hypertension (6%) represented additional contraindications (Figure 1) [21].

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Figure 1. Barriers to intravenous thrombolysis among acute ischemic stroke patients in Saudi Arabia [21]. Categories represent the proportion of thrombolysis-excluded patients with each documented barrier; categories are not mutually exclusive. Delayed emergency department arrival—beyond the therapeutic window—accounts for 77% of exclusions, underscoring the need for population-level awareness campaigns on stroke symptom recognition and rapid response. ED: emergency department.

In a study of posterior circulation stroke, only 22.4% of patients received thrombolysis and/or thrombectomy [22]. Endovascular thrombectomy experience from a single center (n = 369 patients) demonstrated successful recanalization in 84.8% of anterior circulation strokes, with good functional outcome (modified Rankin Scale 0–2 at 90 days) achieved in 41% and mortality of 22.4% [23]. SITS-MENA Registry data showed that Saudi stroke patients were younger (median age 55 vs. 73 years globally) but presented with more severe strokes (NIHSS 12 vs. 9) and higher diabetes prevalence [24].

Regional and international comparisons

Saudi Arabia showed distinct patterns compared with GCC neighbors and international benchmarks. Mean age at first stroke in Saudi Arabia was 63 years, compared to 69 years in the United States and approximately 70 years in the United Kingdom, reflecting premature disease onset in the Saudi population [1, 5].

Among GCC countries from 1990 to 2021, Qatar achieved a 59.9% decrease and the UAE a 50% decrease in age-standardized stroke death rate (best performers), while Kuwait showed a 14.4% increase and Saudi Arabia a modest decrease of only 0.59% (Figure 2) [25]. Saudi Arabia contributed approximately 45% of GCC stroke deaths, 49% of years of potential life lost, and 60% of the regionʼs NCD-related economic losses—estimated at USD 50 billion annually, equivalent to 3.3% of GCC GDP [25].

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Figure 2. Percentage change in age-standardized stroke death rate among selected GCC countries, 1990–2021 [25]. Blue bars indicate countries with decreasing rates; the red bar indicates Kuwait with an increasing rate. Saudi Arabiaʼs –0.59% change contrasts markedly with Qatar (–59.9%) and the UAE (–50%), highlighting comparatively limited progress in stroke mortality reduction. GCC: Gulf Cooperation Council; UAE: United Arab Emirates.

The GCC region overall showed substantially higher obesity prevalence compared to the global average, with over 70% of Saudi adults classified as overweight or obese, particularly among women [25].

Strengths and limitations

Strengths of this study include utilization of standardized GBD methodology enabling international comparisons, comprehensive temporal coverage spanning three decades, and synthesis of multiple data sources including registry and systematic review data.

Several limitations must be acknowledged. GBD estimates for Saudi Arabia are modeled based on incomplete vital registration data, potentially affecting precision. The very high heterogeneity across regional studies (I² = 98.8%) limits the interpretability of the pooled incidence estimate. Regional studies employ heterogeneous methodologies, further limiting direct comparisons. The absence of a national stroke registry prevents precise population-based surveillance. Hospital-based studies may underestimate mild strokes not presenting to healthcare facilities. Expatriate populations (approximately 38% of Saudi Arabiaʼs population) are variably included in surveillance systems, potentially biasing national estimates. No Saudi-specific SDI adjustment was performed, limiting comparative burden analysis. Finally, the COVID-19 pandemic may have influenced GBD estimates for 2020–2021, and post-pandemic data should be analyzed as they become available.

Implications for Vision 2030

Achieving Vision 2030 stroke-related targets requires a multi-pronged intervention. Primary prevention must address the exceptionally high metabolic risk factor prevalence through population-based dietary interventions, physical activity promotion, and diabetes screening and management programs. Secondary prevention requires expanding stroke treatment capacity through the establishment of additional primary stroke centers, public awareness campaigns emphasizing stroke symptom recognition and urgent presentation, and telemedicine networks connecting rural facilities to expert consultation. The current treatment gap represents preventable deaths and disability.

Tertiary prevention and rehabilitation services require development to address the growing population of stroke survivors. With 93% of DALYs attributable to YLLs rather than YLDs, mortality reduction remains paramount, but disability management will become increasingly important as survival improves.

Establishing a nationwide stroke registry should be prioritized to enable accurate surveillance, quality improvement, and evaluation of intervention effectiveness. The Eastern Province Registry experience demonstrates feasibility in the Saudi context [11].

Stroke burden in Saudi Arabia demonstrates encouraging declining trends in mortality and DALYs, yet substantial challenges persist. The younger onset age, high metabolic risk factor prevalence, and critically low treatment utilization rates represent urgent public health priorities. Saudi Arabiaʼs higher-than-expected burden relative to its socioeconomic development level—compounded by a treatment infrastructure gap that has grown relative to international benchmarks—indicates considerable room for improvement. Achieving Vision 2030 health targets will require accelerated implementation of primary prevention strategies targeting diabetes and obesity, substantial expansion of acute stroke treatment infrastructure, and the establishment of comprehensive national surveillance systems.