Background: Aspiration pneumonia is one of the major complications among hospitalized stroke patients with global incidence ranging from five to 83 percent and hospital mortality rate of up to 70 percent. This study aimed to assess the incidence and identify predictors of aspiration pneumonia among stroke patients in Western Amhara region, North West Ethiopia.Methods: An institution-based retrospective follow-up study was conducted on a simple random sample of 568 stroke patients in Western Amhara region admitted at Felege Hiwot referral hospital. Log binomial regression model, a generalized linear model with log link, was applied to identify significant predictors of aspiration pneumonia.Results: Cumulative incidence of aspiration pneumonia among the 568 sampled patients was 23.06%. Males were 1.71 times more at risk to acquire aspiration pneumonia than females (ARR=1.71, 95 percent CI 1.07-2.74). Patients with vomiting and dysphagia were more risky to acquire aspiration pneumonia as compared to patients without vomiting and dysphagia (ARR=1.81, 95 percent CI 1.04-3.14) and (ARR=1.95, 95 percent CI 1.10-3.48) respectively. Patients who received antibiotic prophylaxis and patients with Glasgow Comma Scale greater than twelve were less risky to acquire aspiration pneumonia as compared to who not received antibiotic prophylaxis and Glasgow Comma Scale less than eight (ARR=0.10, 95 percent CI 0.04-0.28), (ARR=0.45, 95 percent CI 0.22-0.94) respectively. Conclusion: The cumulative incidence of aspiration pneumonia among sampled patients was 23.06%. Vomiting, dysphagia, antibiotic treatment and Glasgow Comma Scale showed significant correlation with the acquiring of aspiration pneumonia. Therefore, we recommend health care providers to give special attention for patients with these risk factors to prevent aspiration pneumonia.