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Background Stroke is featured by high mortality and recurrent rate worldwide. Serum uric acid (SUA) is the product of purine metabolism that has been identified as a risk factor for cardiovascular disease. The serum uric acid/serum creatinine ratio (SUA/Scr) is a renal function-normalized SUA. The role of SUA/Scr in acute cerebrovascular disease remains controversial. Objective To identify the correlation of SUA/Scr with the recurrence and mortality of cerebrovascular events in patients with acute cerebrovascular disease. Methods This was a prospective cohort study involving patients with the initial cerebrovascular event consecutively admitted in Tianjin Huanhu Hospital from September 2006 to September 2019. All patients were followed up in the outpatient clinic combined with telephone contact until September 2020. The primary outcome was all-cause mortality. The secondary outcomes were recurrent cerebrovascular events, recurrent cardiovascular events and other vascular events (e.g., arteriovenous thrombosis of lower extremities). Cox proportional hazard models were used to explore the correlation of SUA/Scr with the recurrence and mortality of cerebrovascular events in patients with acute cerebrovascular disease. Results According to the quartiles of SUA/Scr levels, patients with acute cerebrovascular disease were divided into Q1 group (SUA/Scr≤3.16, n=3 520), Q2 group (3.164.92, n=3 243). At the end of the follow-up, 774 (5.8%) patients died, while 2 064 (15.5%) reported recurrences of cerebrovascular events. In Q1-Q4 groups, there were 302, 375, 408 and 337 male cases of recurrences of cerebrovascular events, and 99, 125, 169 and 249 female cases of recurrences of cerebrovascular events, respectively. There were 261, 314, 345 and 283 male cases of recurrences of cerebral infarction, and 90, 101, 142 and 205 female cases of recurrences of cerebral infarction in Q1-Q4 groups, respectively. There were 154, 191, 214 and 183 male cases of recurrences of large atherosclerotic cerebral infarction, and 58, 52, 45 and 31 female cases of recurrences of large atherosclerotic cerebral infarction in Q1-Q4 groups, respectively. All-cause mortality in men was 165, 128, 131 and 88 cases in Q1-Q4 groups, respectively, and 57, 63, 62 and 80 cases in women. The mortality of men due to cerebral infarction was 93, 72, 70, and 46 cases in Q1-Q4 groups, respectively, and 31, 33, 36, and 44 cases in women. The mortality of men due to large artery atherosclerotic cerebral infarction was 58, 52, 45, and 31 cases in Q1-Q4 groups, respectively, and 17, 18, 27 and 24 cases in women. After adjusting for multiple confounding factors, SUA/Scr in Q4 compared with Q1 was an influencing factor for the recurrence of acute cerebral infarction in men (HR=0.690, 95%CI=0.500-0.953, P=0.026). SUA/Scr in Q4 compared with Q1 was an influencing factor for the recurrence of large artery atherosclerotic cerebral infarction in the male cerebral infarction subgroup (HR=0.740, 95%CI=0.578-0.947, P=0.017). SUA/Scr in Q4 compared with Q1 was an influencing factor for all-cause mortality (HR=0.575, 95%CI=0.368-0.901, P=0.003) and death from cerebral infarction in men (HR=0.610, 95%CI=0.353-0.814, P=0.011). SUA/Scr in Q3 (HR=0.656, 95%CI=0.476-0.904, P=0.010) and Q4 (HR=0.582, 95%CI=0.409-0.829, P=0.001) compared with Q1 was an influencing factor for male death after discharge. SUA/Scr in Q4 compared with Q1 was an influencing factor for death due to large artery atherosclerotic cerebral infarction in the male cerebral infarction subgroup (HR=0.580, 95%CI=0.386-0.873, P=0.007) . Conclusion Within a certain range, the increased SUA/Scr ratio in the acute stage of cerebrovascular disease has a certain protective effect on the recurrence and death of cerebrovascular events in male patients. Low SUA/Scr ratio is associated with the increased risk of death and recurrence of male patients with large artery atherosclerotic cerebral infarction, but not correlated with small artery occlusion cerebral infarction and cardiogenic stroke. SUA/Scr is not correlated with cerebrovascular event recurrence or death in female patients.