Thirty-year changes in stroke demographics in the Saudi National Guard Community (1982-1992 and 2013-2024)

Stroke epidemiology in Saudi Arabia has evolved substantially over three decades due to advances in clinical care, diagnostic technology, and demographic change. This study descriptively compares stroke characteristics, risk factors, and outcomes in the Saudi National Guard (SANG) community across two historical periods, acknowledging important methodological constraints on cross-period comparability.

A retrospective comparative study analyzed 3,436 stroke patients from June 2013 to January 2024 at King Abdulaziz Medical City, Riyadh (primary registry data), compared with 500 patients from December 1982 to June 1992 [secondary data derived from Al Rajeh et al.]. Patients with transient ischemic attack or stroke mimickers were excluded. Variables included demographics, vascular risk factors, stroke type (TOAST classification with retrospective mapping for the historical period), crude incidence, prevalence, mortality, and - for the Modern Era only - functional outcome (mRS 0-2 at 3 months) and length of stay (LOS). A new age-stratified analysis was performed using individual-level data from 3,434 Modern Era patients. All risk ratios (RRs) are unadjusted descriptive estimates.

Crude annual stroke incidence appears to have decreased from 43.8 to 34.36 per 100,000 (unadjusted RR 0.79, 95% CI 0.67-0.92), and 10-year period prevalence increased from 186 to 343.6 per 100,000. Importantly, the Modern Era cohort had a lower mean age (59.8 ± 13.3 years) than the historical cohort (63 years), indicating the apparent incidence decline is not attributable to demographic aging. Risk factors increased substantially: hypertension (72.1% vs. 56.0%), diabetes mellitus (64.1% vs. 42.0%), and smoking (16.9% vs. 6.0%). Intracerebral hemorrhage declined (14.6% vs. 21.4%). All-cause mortality fell from 12.2 to 4.2% (unadjusted RR 0.34, 95% CI 0.25-0.46), the sole outcome for which direct cross-period comparison is feasible. In the Modern Era, 56.8% of patients with available data achieved mRS 0-2 at 3 months (descriptive, no historical comparator).

These descriptive observations are consistent with global patterns of declining stroke mortality and rising metabolic risk burden. All cross-period comparisons must be interpreted cautiously given differences in diagnostic technology, data sources, population composition, and the absence of age-sex standardized rates. The rising metabolic risk factor burden underscores the urgent need for targeted primary prevention strategies in this community.