Stroke burden and epidemiological trends in Saudi Arabia: 1990–2023

OBJECTIVES: Stroke represents a leading cause of mortality and disability globally, yet comprehensive epidemiological analyses for Saudi Arabia remain limited. This study aimed to analyze temporal trends in stroke incidence, mortality, and disability-adjusted life years (DALYs) in Saudi Arabia from 1990 to 2023, examine stroke subtype distributions and risk factor attributions, and compare findings with regional and international benchmarks. METHODS: We conducted a comprehensive analysis of the Global Burden of Disease (GBD) 2023 study data for Saudi Arabia, supplemented by systematic review findings and hospital-based registry data. Age-standardized incidence rates, age-standardized mortality rates, and DALY rates were extracted for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Annual percentage change was calculated using Joinpoint regression with grid search algorithm and permutation tests. Risk factor attribution was analyzed using comparative risk assessment methodology. Poisson regression models with log-link function and robust variance estimators examined sex differences. RESULTS: Based on GBD 2023 estimates, age-standardized stroke incidence in Saudi Arabia showed initial increases from 1990 to 2014, followed by stabilization through 2023. Age-standardized DALYs demonstrated significant yearly decreases of −9.28/100,000 (95% confidence interval [CI]: −12.26 to −6.31, P < 0.001). The age-standardized death rate was 85.2/100,000 (95% uncertainty interval: 76.8–94.3) in 2023, representing a 29.5% decrease from 1990. Supplementary data from regional studies showed a pooled annual stroke incidence of 29/100,000 (95% CI: 15–47), with regional variation from 13.89 to 57.64/100,000. Ischemic stroke (IS) predominated, comprising 79%–87% of cases. The mean age at first stroke was 63 years, 6 years younger than that of Western populations. Risk factor analysis revealed hypertension (57.7%), diabetes mellitus (49.4%), and obesity (42.0%) as major modifiable contributors. Saudi Arabia demonstrated a higher-than-expected stroke burden relative to its socio-demographic index. Hospital-based data indicated intravenous thrombolysis utilization remained critically low at 1%–3.6% of eligible patients, though these rates represent selected institutions and may not be nationally representative. CONCLUSIONS: Despite declining mortality and DALYs, Saudi Arabia faces a substantial stroke burden characterized by a younger onset age and significant treatment gaps. Achieving Vision 2030 health targets requires accelerated implementation of primary prevention programs addressing metabolic risk factors and expansion of acute stroke treatment capacity nationwide.