Background-High-resolution MRI has been shown to be capable of distinguishing intact, thick fibrous caps from thin and ruptured caps in human carotid atherosclerosis in vivo. The aim of this study was to determine whether MRI identification of fibrous cap thinning or rupture is associated with a history of recent transient ischemic attack (TIA) or stroke. Methods and Results-Fifty-three consecutive patients (mean age, 71 years; 49 male) scheduled for carotid endarterectomy were recruited after obtaining informed consent. Twenty-eight subjects had a recent history of TIA or stroke on the side appropriate to the index carotid lesion, and 25 were asymptomatic. Preoperative carotid MRI was performed in a 1.5-T GE Signa scanner that generated T 1 -, PD-, and T 2 -weighted and three-dimensional time-of-flight images. Using previously reported MRI criteria, the fibrous cap was categorized as intact-thick, intact-thin, or ruptured for each carotid plaque by blinded review. There was a strong and statistically significant trend showing a higher percentage of symptomatic patients for ruptured caps (70%) compared with thick caps (9%) (Pϭ0.001 Mann-Whitney test for cap status versus symptoms). Compared with patients with thick fibrous caps, patients with ruptured caps were 23 times more likely to have had a recent TIA or stroke (95% CIϭ3, 210). Conclusions-MRI identification of a ruptured fibrous cap is highly associated with a recent history of TIA or stroke.Ongoing prospective studies will determine the predictive value fibrous cap characteristics, as visualized by MRI, for risk of subsequent ischemic events. Key Words: magnetic resonance imaging Ⅲ atherosclerosis Ⅲ carotid arteries Ⅲ stroke R upture of the fibrous cap that overlies the thrombogenic necrotic core is presently believed to play an important role in acute ischemic events, such as stroke, transient ischemic attack, myocardial infarction, and unstable angina. [1][2][3][4] Several histological studies have revealed that lesions associated with the development of ischemic symptoms typically contain a large necrotic core that is separated from the lumen by a fibrous cap that is thin or disrupted. 5,6 Because the detection of these morphological features could identify the plaques that represent a higher risk for thromboembolic complications, the development of a noninvasive method capable of assessing the state of the fibrous cap would not only improve patient stratification to medical or surgical treatment but would also provide a means of monitoring disease progression or evaluating the efficacy of therapeutic interventions.Of the clinical imaging modalities presently used to study atherosclerosis, MRI is unique because it is noninvasive, capable of identifying plaque tissue components with submillimeter resolution, able to provide quantitative measures of disease severity, and suitable for serial investigations. [7][8][9][10][11][12][13][14] Recent studies demonstrated that high-resolution MRI is capable of distinguishing intact, thick fibrous caps from thin o...