BACKGROUND AND PURPOSE:Intracranial atherosclerotic plaque features are potential factors associated with recurrent stroke, but previous studies only focused on a single lesion, and few studies investigated them with perfusion impairment. This study aimed to investigate the association among whole-brain plaque features, perfusion deficit, and stroke recurrence. MATERIALS AND METHODS:Patients with ischemic stroke due to intracranial atherosclerosis were retrospectively collected and categorized into first-time and recurrent-stroke groups. Patients underwent high-resolution vessel wall imaging and DSC-PWI. Intracranial plaque number, culprit plaque features (such as plaque volume/burden, degree of stenosis, enhancement ratio), and perfusion deficit variables were recorded. Logistic regression analyses were performed to determine the independent factors associated with recurrent stroke. RESULTS:One hundred seventy-five patients (mean age, 59 [SD,12] years; 115 men) were included. Compared with the first-time stroke group (n ¼ 100), the recurrent-stroke group (n ¼ 75) had a larger culprit volume (P ¼ .006) and showed more intracranial plaques (P , .001) and more enhanced plaques (P ¼ .003). After we adjusted for other factors, culprit plaque volume (OR, 1.16 per 10mm 3 increase; 95% CI, 1.03-1.30; P ¼ .015) and total plaque number (OR, 1.31; 95% CI, 1.13-1.52; P , .001) were independently associated with recurrent stroke. Combining these factors increased the area under the curve to 0.71. CONCLUSIONS:Large culprit plaque and more intracranial plaques were independently associated with recurrent stroke. Performing whole-brain vessel wall imaging may help identify patients with a higher risk of recurrent stroke.ABBREVIATIONS: HR-VWI ¼ high-resolution vessel wall imaging; IQR ¼ interquartile range I ntracranial atherosclerosis is the primary etiology of stroke in Asia, 1 and the risk of recurrent stroke in these patients is high even under aggressive medication. 2 Identification of the risk factors associated with recurrent stroke is essential for secondary stroke prevention.The degree of stenosis is a well-recognized predictor of recurrent stroke, and patients with .50% stenosis are recommended for more aggressive treatment. 3,4 However, vulnerable atherosclerotic plaques with ,50% stenosis can also lead to stroke events. 5,6 The development of high-resolution vessel wall imaging (HR-VWI) has enabled the visualization of vulnerable features (intraplaque hemorrhage, outward remodeling, neurovascularture) in vivo and has provided important insight into plaque vulnerability rather than the degree of stenosis alone. 7,8 The use of whole-brain HR-VWI also allows the evaluation of multiple lesions simultaneously. 9Previous HR-VWI studies of intracranial plaques focused on comparing patients with stroke and asymptomatic patients. 10,11 However, investigations of intracranial plaque features associated with recurrent stroke are still rare. A few studies found that plaque enhancement 12 and plaque burden 13 were associated with...