Introduction

Stroke remains a major cause of death and disability in India, with an incidence rate of 108 to 172 cases per 100,000 population and high short-term mortality. Compared with Western countries, strokes in India occur at a younger age and are associated with higher case fatality rates. Stroke care is further challenged by significant regional differences, urban-rural disparities in access to services, low public awareness, delays in seeking treatment, limited acute care facilities, and inadequate rehabilitation services.

Despite the growing burden, national stroke data have been limited. The ICMR-NCDIR National Stroke Registry Programme (NSRP) addresses these gaps through Hospital-Based Stroke Registries (HBSRs), which systematically collect standardized data on stroke patients across diverse healthcare settings. These registries provide valuable evidence to guide policy decisions, resource allocation, and improvements in stroke care across India.

Aim

To address the critical knowledge gaps in stroke management in India by analysing data from stroke registries.

Patient Profile

• Patients either with first-ever stroke or recurrent stroke reporting at the registry hospitals within 28 days of onset of stroke. (age ≥ 18 years).
• First-ever stroke was the first stroke in a person's lifetime, while recurrent stroke was any new stroke occurring more than 21 days after the initial stroke or earlier if it affected a different vascular territory.

Methods

Study Design

Data Collection & Processing

• The study collected data on patients’ demographics, clinical features, risk factors, diagnosis, and treatment. 
• Stroke cases were classified into ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), venous stroke, or undetermined stroke (UD; when imaging data were unavailable). 
• Patients were followed up at 28 days and 3 months to assess disability [using the modified Rankin Scale (mRS)] and recurrent stroke events. 
• Data from 30 hospital centres across India, enrolled between 2020 and 2022, were included in the analysis.

Results

• Between 2020 and 2022, 34,792 stroke cases were registered. The cohort was predominantly male (63.4%), mean age of the study population was 59.4 ±13.9 years. Most cases occurred in middle-aged adults (45 to 64 years), while 13.8% patients were younger than 45 years. The study population was largely drawn from rural communities, and the vast majority (90%) received care through hospital admission rather than outpatient services.
• Early hospital presentation was limited, with only 20.1% of patients arriving within 4.5 hours of symptom onset and 5.3% within the first hour (golden hour). 
• The most common presentation was motor weakness (74.8%), followed by speech disturbances (51.2%), dysphagia (30.4%), and impaired consciousness (25.6%), with nearly 75% presenting with multiple symptoms. 
• Stroke severity was predominantly moderate (NIHSS 5-14; ~50%), while 7.8% had severe stroke (NIHSS 21-42). 
• Ischemic stroke (60%) was the most common subtype, followed by ICH and SAH, whereas venous stroke and UD each accounted for <2% of cases. 
• Among IS, large artery atherosclerosis (55.9%) was the leading etiology, followed by small vessel occlusion (18.2%) and undetermined causes (13.8%). Cardioembolic stroke represented 8.1% of ischemic strokes and was more frequent in women (9.4% vs. 7.4% in men). Stroke recurrence was also higher among men compared with women ((12.7% vs.~10%).
• Hypertension was the most common risk factor, present in approximately 75% of stroke patients. Other key risk factors included diabetes, tobacco use, alcohol consumption (mainly in men), and anemia. 
• Neuroimaging was performed in 98.3% of cases, with CT alone (64.5%) being the most commonly used modality. Nearly 15.7% patients underwent magnetic resonance imaging (MRI), of these; 5.5% underwent MRI alone. CT/MR angiography was performed in 15.9% of the cases (13% was done for IS cases).
• Among 20,887 IS patients, 4.6% received intravenous thrombolysis and 0.7% underwent mechanical thrombectomy. Delayed presentation was the major barrier to thrombolysis (74.5%), followed by imaging delays (12.6%) and medication unavailability (11.0%). Serious thrombolysis-related complications were uncommon, seen in 1.9% of the IS patients. Less than 2% of the study population underwent surgical procedure or intervention. 
• Of the entire study population affected with IS, 11.2% and 1.4% had received antiplatelets and anticoagulants, respectively, before arrival to the reporting hospital. During hospitalization, 87.4% of IS patients received antiplatelet therapy and 19.1% received anticoagulants.
• The median hospital stay was 6 days, with about half of patients remaining hospitalized for 3-7 days. 
• The in-hospital mortality rate was 13.9%, increasing to 24.2% at 28 days and 27.8% at 3 months. 
• At discharge, 67.7% of patients had moderate-to-severe disability (mRS 3-5). Although mortality was similar between sexes, disability was more frequent in women (71.2%) than men (65.9%), and this difference persisted at follow-up. By 3 months, only 32% of women were functionally independent (mRS 0-2) compared with ~40% of men.
• Functional outcomes improved over time, with 43% of patients remaining disabled at 28 days and 29.7% at 3 months, while 37% of survivors were disability-free by 3 months. Mortality at 3 months was highest among UD stroke patients (65.6%), followed by hemorrhagic stroke (36.1%) and IS (21.8%). 
• Ischemic stroke showed the most favorable recovery, with 42.9% achieving no disability compared with 28.0% among hemorrhagic stroke patients.
• Overall, 1.1% of patients experienced stroke recurrence within 3 months. Recurrence occurred in 1.0% of those with a first-ever stroke and 2.0% of those who had a prior recurrent stroke at admission.

Conclusions

This large multi-centre hospital-based registry highlights the substantial burden of stroke in India and provides important insights into its clinical profile, risk factors, treatment patterns, and outcomes. 

The findings indicate significant challenges in acute stroke care, including delayed hospital presentation, low utilization of reperfusion therapies, and limited access to advanced stroke interventions. 

Despite available treatments, stroke was associated with high mortality and disability rates, underscoring the need for improved prevention strategies, timely diagnosis and treatment, and stronger post-stroke follow-up and rehabilitation services to enhance patient outcomes.

Int J Stroke. 2026 Jul;21(6):827-838.