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Background: Serum cardiac troponin can be increased in acute ischemic stroke and regarded as a prognostic marker after stroke as similar as coronary artery disease (CAD). However, interpretation of troponin elevation in ischemic stroke patients is complex. Therefore, the aim of this study was to elucidate the possible causes and long-term prognostic value of troponin elevation in ischemic stroke patients.Methods: In a prospective, single center cohort study, we performed serial measurement of serum troponin and 12-lead electrocardiogram (ECG) at 48 hours after stroke onset followed by admission. Based on troponin I level at 48 hours, patients were categorized into 3 groups; elevated (≥0.04 ng/mL), minimally elevated (0.040-0.010 ng/mL) and non-detectable (<0.010 ng/mL) level. Comorbidities with possible impact on troponin elevation were documented based on either historical information or abnormalities in disease-related biomarkers. The primary endpoint was death and major adverse cardiac and cerebrovascular event (MACCE).Results: Among 1092 consecutive patients during 2-year period, 145 patients (13.3%) and 335 patients (30.7%) had a positive and minor elevation troponin. Multivariable analysis identified six-comorbidities included atrial fibrillation (AF), hypertrophic myocardium (HM), heart failure (HF), chronic kidney disease (CKD), active cancer and possibly ischemic heart disease (IHD), and composite neurological factor (defined as moderate to severe deficits or insular lesions) associated with troponin elevation. In a multivariate Cox model, minimally and elevated troponin were independently associated with death (hazard ratio [HR]: 1.77, 95% confidence interval [CI]: 1.07-2.91 for minor elevation and HR: 3.63, 95% CI: 2.13-6.19 for positive troponin) and combined endpoints of MACCE.Conclusions: Troponin elevation even minor elevation are associated with mortality and MACCE in patients with acute stage of ischemic stroke.