Prothrombotic States in Acute Ischemic Stroke: Real-world Evidence on Clinical Features and Outcomes from Hospital-Based Stroke Registry Program in India

Abstract Background and Objectives: Prothrombotic states (PSs) are important but underrecognized contributors to acute ischemic stroke (AIS), particularly in resource-limited settings where thrombophilia testing is not routinely available. This study estimated the prevalence and spectrum of PSs in AIS and compared clinical characteristics and outcomes across risk categories. Methods: This study used multicenter registry-based observational cohort data from 77 Indian Council of Medical Research-National Institute of NCD Epidemiology (ICMR-NINE) Hospital-Based Stroke Registries in India (2020–2025). Adults (≥18 years) with clinically and radiologically confirmed AIS were included. Clinical characteristics were compared across hyperhomocysteinemia and inherited (H&I), acquired, and triggering PSs, conventional risk factors, and no-risk-factor categories. Binary logistic regression identified predictors of poor 90-day functional outcome (modified Rankin Scale ≥3). Results: Among 69,734 AIS patients, 3,109 (4.5%) had documented PSs. H&I (3.12%) was most common, followed by acquired (0.75%) and triggering conditions (0.72%). Patients with PSs were younger and had fewer conventional risk factors. Large artery atherosclerosis, multiple brain-area involvement, and multi-territory infarcts were more frequent. Acquired states were more frequent among patients with greater stroke severity and were observed more frequently among those who experienced higher in-hospital mortality (11.6%) and 90-day mortality (32.1%). In adjusted analyses, acquired states independently predicted poor outcomes [adjusted odds ratio (aOR): 1.91; 95% confidence interval: 1.53–2.40], whereas H&I (aOR: 0.63) and triggering states (aOR: 0.75) were associated with lower odds of poor outcome than conventional risk factors. Conclusions: PSs account for a small but clinically important proportion of AIS in India. Acquired PSs are associated with worse prognosis, underscoring the need for targeted evaluation and context-specific guidelines in resource-limited settings.