BACKGROUND AND PURPOSE Besides the severity of carotid artery stenosis, atherosclerotic plaque composition is an important determinant of cerebral symptoms. We analyzed the relationship between the composition of the atherosclerotic plaque at the carotid artery bifurcation and ipsilateral ischemic cerebral lesions on MR imaging. METHODS Forty-one patients with symptomatic carotid artery stenosis (>70%) underwent black-blood, fast spin-echo imaging of the carotid artery and turbo fluid-attenuated inversion recovery (t-FLAIR) imaging of the brain. Plaque regions with a relative decrease in signal intensity in the plaque from proton density-weighted (TE = 14 ms) to T2-weighted (TE = 50 ms) imaging were considered to be lipid cores. We assessed the number and location of infarcts in the ipsilateral cortex, basal ganglia, and centrum semiovale, and hyperintense white matter lesions on t-FLAIR images. RESULTS Lipid in the atherosclerotic plaque at the carotid bifurcation was seen in 25 patients. Ipsilateral infarctions were seen in 22 (54%); most often, it involved the centrum semiovale. Patients with a lipid core had an ipsilateral infarct more often than patients without a lipid core (68% vs. 31%; P = .03). Centrum semiovale infarcts were more frequent (56% vs. 25%, P = .06) and the median number of centrum semiovale infarcts was higher P = .04) in patients with a lipid core than in patients without a lipid core. CONCLUSION Ischemic cerebral lesions were common in patients with symptomatic carotid artery disease. Plaque composition, as assessed with MR imaging, is related to the presence and extent of ischemic cerebral lesions.