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Intracranial atherosclerotic disease (ICAD) accounts for 9–15% of ischemic stroke in the United States. Although highly stenotic ICAD accounts for most of the strokes, it is assumed that nonstenotic ICAD (nICAD) can result in stroke, despite being missed on standard luminal imaging modalities. We describe a patient with nICAD who suffered recurrent thromboembolic stroke and TIA but had a negative conventional stroke workup. As a result, they were referred for high-resolution magnetic resonance imaging (HR-MRI) of the arterial vessel wall, which identified a nonstenotic plaque with multiple high-risk features, identifying it as the etiology of the patient’s thromboembolic events. The diagnosis resulted in a transition from anticoagulation to antiplatelet therapy, after which the patient’s clinical events resolved. HR-MRI is an imaging technique that has the potential to guide medical management for patients with ischemic stroke, particularly in cryptogenic stroke.

Nonstenotic Culprit Plaque: The Utility of High-Resolution Vessel Wall MRI of Intracranial Vessels after Ischemic Stroke