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Abstract Introduction Guanidino compounds, including l -homoarginine (l -hArg), symmetric dimethylarginine (SDMA), asymmetric dimethylarginine (ADMA) and l -arginine (l -Arg) are associated with mortality, fatal strokes, stroke incidence, and atherosclerosis. Objectives We aimed to study the association of guanidino compounds (l -hArg/ADMA and l -hArg/SDMA) with stroke etiology, internal carotid artery (ICA) stenosis and CHA 2 DS 2 -VASc score in patients with cerebrovascular disease. Methods We analyzed l -hArg, SDMA, ADMA, l -Arg, and compound molar ratios, i.e. l -hArg/ADMA and l -hArg/SDMA, in 272 patients with cerebrovascular disease in a cross-sectional discovery cohort and two cross-sectional validation cohorts of acute stroke patients from Germany (n = 137) and UK (n = 394). The guanidino compound levels were compared with clinical, imaging, and ultrasound parameters. Results Low l -hArg/ADMA and l -hArg/SDMA molar ratios predicted territorial infarcts (OR 1.74; 95% CI 1.34–2.26 and OR 1.64; 95% CI 1.26–2.15, respectively) and were associated with stroke subtypes due to large vessel disease or cardio-embolism (OR 1.52; 95% CI 1.12–2.06 and OR 2.01; 95% CI 1.35–3.00, respectively) in meta-analysis of the discovery and validation cohort data. In line with these results, a low l -hArg/ADMA and l -hArg/SDMA molar ratio was found in patients with ICA stenosis (OR 0.73; 95% CI 0.55–0.97 and OR 0.69; 95% CI 0.50–0.94, respectively) in the discovery and validation cohort. Furthermore, guanidino compound ratios (i.e. l -hArg/ADMA and l -hArg/SDMA) were strongly correlated with CHA 2 DS 2 -VASC score (p <.001) in all three cohorts. Discussion The results from these three cross-sectional studies reveal that guanidino compound ratios (i.e. l -hArg/ADMA and l -hArg/SDMA) can discriminate stroke etiologies, predict ICA stenosis and estimate risk prediction in patients with cerebrovascular disease. Graphical abstract Unlabelled Image Highlights • Low l -hArg/ADMA and l -hArg/SDMA are associated with territorial stroke. • l -hArg/ADMA and l -hArg/SDMA ratios are low in the presence of carotid stenosis • Low l -hArg/ADMA and l -hArg/SDMA correlate with an increased risk prediction score. [ABSTRACT FROM AUTHOR]