Introduction: Worldwide, more than 5.7% of the population reside above 1,500 m of elevation. It has been hypothesized that acute short-term hypoxia exposure could increase the risk of developing a stroke. Studies assessing the effect of altitude on stroke have provided conflicting results, some analyses suggest that long-term chronic exposure could be associated with reduced mortality and lower stroke incidence rates.</p> Methods: An ecological analysis of all stroke hospital admissions, mortality rates, and disability-adjusted life years in Ecuador was performed from 2001 to 2017. The cases and population at risk were categorized in low (<1,500 m), moderate (1,500-2,500 m), high (2,500-3,500 m), and very high altitude (3,500-5,500 m) according to the place of residence. The derived crude and direct standardized age-sex adjusted mortality and hospital admission rates were calculated.</p> Results: A total of 38,201 deaths and 75,893 stroke-related hospital admissions were reported. High altitude populations (HAP) had lower stroke mortality in men [OR: 0.91 (0.88-0.95)] and women [OR: 0.83 (0.79-0.86)]. In addition, HAP had a significant lower risk of getting admitted to the hospital when compared with the low altitude group in men [OR: 0.55 (CI 95% 0.54-0.56)] and women [OR: 0.65 (CI 95% 0.64-0.66)].</p> Conclusion: This is the first epidemiological study that aims to elucidate the association between stroke and altitude using four different elevation ranges. Our findings suggest that living at higher elevations offers a reduction or the risk of dying due to stroke as well as a reduction in the probability of being admitted to the hospital. Nevertheless, this protective factor has a stronger effect between 2,000 and 3,500 m.</p>