Ischemic stroke in Brazil (2017–2025): Trends in admissions, thrombolysis, craniectomy, costs, and COVID-19 disruption

BACKGROUND: Ischemic stroke (IS) is a leading cause of mortality and long-term disability in Brazil. However, national-level data on seasonal patterns, therapeutic trends, and COVID-19-related disruptions remain scarce. METHODS: We conducted a retrospective study using the Brazilian national public health database (DataSUS) to analyze all IS hospitalizations from January/2017 to June/2025. Outcomes included monthly and annual trends in admission volume, in-hospital mortality, thrombolysis, decompressive craniectomy, length of stay, and costs. We applied Seasonal-Trend decomposition using Loess (STL) and Chow tests to assess structural breaks due to the COVID-19 pandemic. RESULTS: A total of 1,666,631 IS hospitalizations were analyzed. Admissions increased from 174, 315 in 2017 to 221,914 in 2024. A sharp drop occurred in 2020 (175,555), coinciding with the pandemic's onset (Chow-test p < 0.001), followed by full recovery in 2022-2025. A seasonal peak was observed during winter (June-August). In-hospital mortality peaked in 2021 (16.22%), and declined to 14.0% (2024). Thrombolysis use rose modestly from 1.5% to 2.7% over the period, remaining below international standards. Decompressive craniectomies rose until 2021 (1,024 cases), with a slight decline in 2022. Total hospitalization costs increased from R$ 241,9 million (USD 75,8 million) in 2017 to R$ 437.8 million (USD 83.4 million) in 2024, after adjusting for inflation, while average cost per admission reached R$ 1.973 (USD 376). CONCLUSION: IS hospitalizations in Brazil have risen over time, with seasonal variation and significant disruption during the pandemic. Thrombolysis remains underutilized. Findings highlight the need to strengthen stroke systems of care and improve access to reperfusion therapies across the Brazilian public healthcare system.