Background:Diagnosis of cerebrovascular disease is based on both clinical and radiological findings, however, they do not always correlate.Aims:To investigate ischemic stroke recurrence and mortality in patients with different imaging phenotypes of ischemic cerebrovascular disease.Methods:Within the SMART-MR study, a prospective patient cohort with arterial disease, cerebrovascular diseases of participants at baseline were classified as no cerebrovascular disease (reference group,n= 828), symptomatic cerebrovascular disease (n= 204), covert vascular lesions (n= 156), or imaging negative ischemia (n= 90) based upon clinical and MRI findings. Ischemic strokes and deaths were collected at 6 month-intervals up to 17 years of follow-up. With Cox regression, relationships between phenotype and ischemic stroke recurrence, cardiovascular mortality, and non-vascular mortality were studied adjusted for age, sex, and cardiovascular risk factors.Results:Compared to reference group risk for recurrent ischemic stroke was increased not only in the symptomatic cerebrovascular disease (HR 3.9, 95% CI 2.3–6.6), but also in the covert vascular lesion (HR 2.5, 95% CI 1.3–4.8) and the imaging negative ischemia groups (HR 2.4, 95% CI 1.1–5.5). Risk for cardiovascular mortality was increased in the symptomatic cerebrovascular disease (HR 2.2, 95% CI 1.5–3.2) and covert vascular lesions groups (HR 2.3, 95% CI 1.5–3.4), while the risk was less strong but also increased in the imaging negative ischemia group (HR 1.7, 95% CI 0.9–3.0).Conclusions:People with all imaging phenotypes of cerebrovascular disease have increased risk of recurrent ischemic stroke and mortality compared to other arterial diseases. Strict preventive measures should be performed even when imaging findings or clinical symptoms are absent.Data access statement:For use of anonymized data, a reasonable request has to be made in writing to the UCC-SMART study group and the third party has to sign a confidentiality agreement.