A stroke registry was established in the Eastern Province of Saudi Arabia with an estimated population of 750,000 inhabitants of whom 545,000 are Saudi citizens. The register started in July 1989 and ended in July 1993. The Gulf war led to its interruption from August 1990 to August 1991. Four hundred eighty-eight cases (314 males, 174 females) of first-ever strokes affecting Saudi nationals were registered over the 3-year period. The crude incidence rate for first-ever strokes was 29.8/100,000/year (95% CI: 25.2-34.3/100,000 year). When standardized to the 1976 US population, it rose up to 125.8/100,000/year. Ischemic strokes (69%) predominated as in other studies but subarachnoid hemorrhage (SAH) was extremely rare (1.4%). The important risk factors were: systemic hypertension (38%), diabetes mellitus (37%), heart disease (27%), smoking (19%) and family history of stroke (14%). Previous transient ischemic attacks (3%) and carotid bruits (1%) were uncommon. The 30-day case fatality rate was 15%. The study showed that the age-adjusted stroke incidence rate for Saudis in this region is lower than the rates reported in developed countries but within the range reported worldwide. The pattern of stroke in Saudi Arabia is not different from that reported in other communities with the exception of the low incidence of SAH. The risk factors are similar to findings in other studies except for the high frequency of diabetes mellitus in our cases. The lower mortality rate was probably due to the younger age of the population and the availability of free medical services for management of cases.