Background: Ischemic stroke remains a major global health concern, with notable disparities in outcomes between rural and urban population in South Asia. Regional resource distribution, care disparities and demographic factors may exacerbate rural mortality. Objective: This study aimed to asses ischemic stroke mortality and age based prevalence incidence in Peshawar, comparing rural and urban population survival and incidence. Methods: A retrospective cross sectional chart review was conducted at two tertiary care hospitals of Peshawar from August 2024 to February 2025. We evaluated adults greater than or equal to 18 years diagnosed with ischemic stroke. Data included demographics, co-morbidities, residential status and in-hospital mortality. SPSS v27.0 was used for descriptive analysis and inferential statistics (Chi-square, Fischer’s Exact Test), with p<0.05 as significance threshold; one-sided tests were applied for directional hypothesis. Results: Off 144 patients (mean age=64.3 ± 13 years; 54.2% males), 84.7% resided in Urban areas. Overall mortality was 18.8%. Rural mortality was nearly double that of Urban patients (31.8% vs. 16.4%; 0ne-sided p=0.084, two-sided p=0.133). Age-stratified analysis showed peak mortality at 91-100 years (66.7%). Conclusion: A clear trend towards higher rural ischemic stroke mortality emerged, underscoring the need for enhanced rural stroke services and policy reforms.