To explore the clinical characteristics of patients with large-artery atherosclerosis type (LAA) and non-LAA with phlegm-heat syndrome in acute ischemic stroke and to provide a reference for the treatment of this disease.

Based on the China Stroke Registry for Patients with Traditional Chinese Medicine registration platform, a cross-sectional study was conducted to enroll patients with acute ischemic stroke and phlegm-heat syndrome with clear etiological classification from September 2022 to February 2025. The patients were divided into the LAA and non-LAA groups, and the demographic data, four traditional Chinese medicine (TCM) diagnosis information, neurological deficits, and laboratory indicators of the two groups were compared.

A total of 196 patients were enrolled, with 110 and 86 patients in the LAA and non-LAA groups, respectively. No significant differences in age, sex, and modified Rankin Scale score at admission were observed between the two groups (P > 0.05). In terms of TCM clinical manifestation, the frequency of weakness (81/110, 73.64%), deep-colored urine (48/110, 43.64%), choking cough after drinking (35/110, 31.82%) in the LAA group were significantly higher than those in the non-LAA group (P < 0.05): weakness (49/86, 56.98%), deep-colored urine (24/86,27.91%), and choking cough after drinking (15/86,17.44%). Among tongue and pulse manifestations, cyanotic sublingual vessels (51/110, 46.36%) were significantly more common in the LAA group than in the non-LAA group (26/86, 30.23%). In contrast, petechia or ecchymosis on the tongue was significantly lower in the LAA group (13/110, 11.82%) than in the non-LAA group (21/86, 24.42%) (P < 0.05). No significant differences in stroke severity or scores were observed between the two groups (P > 0.05), nor were any significant differences in laboratory parameters (P > 0.05).

Significant differences were observed in some TCM clinical manifestation and tongue and pulse manifestations between the LAA and non-LAA groups in patients with acute ischemic stroke with phlegm-heat syndrome. The incidence of weakness, deep-colored urine, choking cough after drinking, and cyanotic sublingual vessels is higher in the LAA group, whereas the incidence of petechia or ecchymosis on the tongue is relatively higher in the non-LAA group. These results provide a reference for the clinical diagnosis and treatment of the disease.