Temporal Trends and Demographic Contributions to Stroke Burden in India, 1990–2023: An Analysis of Global Burden of Disease 2023 Estimates Using Shapley Decomposition and Joinpoint Regression

Background: Stroke is an important cause of death and disability in India, with demographic change potentially obscuring improvements in age-standardized outcomes.Objectives: The objectives of this study were to assess temporal trends in stroke incidence, prevalence, mortality, and disability-adjusted life years (DALYs) in India from 1990 to 2023; to describe age-, sex-, geographic-, and stroke subtype-specific patterns; and to quantify the contributions of population growth, population ageing, and epidemiological change to changes in the absolute stroke burden.Methods: Global burden of disease (GBD) 2023 estimates for India were analysed for 1990-2023.Absolute number of cases and crude and age-standardized rates were examined by age, sex and geographic location.Joinpoint regression assessed temporal trends in age-standardized incidence, mortality, and DALY rates, while Shapley decomposition quantified the contributions of growing population, population ageing, and epidemiological change.Results: Incident stroke cases rose from approximately 0.73 million to 1.87 million (an increase of 155.1%), deaths from approximately 0.42 million to 1.03 million (an increase of 148.2%), and DALYs from 12.41 million to 25.99 million (109.4%).Despite this increase, age-standardized incidence remained stable (average annual percent change (AAPC), -0.0195%; P=0.079584), whereas age-standardized deaths (AAPC, -0.4013) and DALY rates (AAPC, -0.5393) declined significantly (both P<0.001).Burden of stroke increased with age and was generally higher among males, with substantial geographic heterogeneity.A growing and ageing population was the major contributor to the rise in incidence, deaths, and DALYs, while epidemiological change partially offset these effects.Conclusion: India's stroke burden is shaped by population growth and ageing rather than worsening agestandardized risk alone.Declines in age-standardized mortality and DALY rates represent favourable changes in these measures of stroke burden, while the increasing prevalence indicates that improvements have not been uniform across all epidemiological measures.The growing absolute burden underscores the need for intensified risk-factor prevention alongside continued expansion of acute stroke care, rehabilitation, and long-term support.