Objectives This study investigated the association between the pre-miRNA146a C>G rs2910164 polymorphism and serum TNF-α in Egyptian patients with IS. Methods A case-control study was conducted on 75 Egyptian cases with IS and 75 sex-matched control subjects aged 57–65 years. Genomic DNA analysis of pre-miRNA146a and TNF-α measurement was performed with real-time PCR and ELISA, respectively. Results There was a statistically significant difference between cases of ischemic stroke (IS) and control subjects in pre-miRNA146a rs2910164 GG genotype (p=0.017) and G allele (p=0.005). The pre-miRNA146a rs2910164 is significantly associated with large artery atherosclerosis [LAA] in GG genotypes (p=0.019) and G alleles (p=0.004) compared to control subjects. There was a highly statistically significant increase in TNF-α levels (p<0.001) in IS compared to the control group. There was also a statistically significant increase in TNF-α levels (p=0.001) in GG genotypes in IS. Conclusions Our results showed that there was a statistically significant association between pre-miRNA146a rs2910164 GG genotype and susceptibility to IS and LAA. In addition, there was a statistically significant association between pre-miRNA146a rs2910164 GG genotype and TNF-α in IS subjects.