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To investigate the potential difference in the size of the lipid-rich necrotic core (LRNC) in carotid plaques of symptomatic patients versus asymptomatic patients. Pathological studies established that a large LRNC is an important feature of vulnerable atherosclerotic plaque. Previously, we have demonstrated a high correlation between semiquantitative analysis of the LRNC size in T1-weighted (w) turbo field echo (TFE) MR images and histology.Thirty-seven patients with carotid stenosis >70% with (n = 26) or without (n = 11) symptoms were included. Three independent MR readers quantified the amount of LRNC with a T1w TFE pulse sequence. The relative amount of LRNC (LRNC score) was defined as sum of cross-sectional area percentages LRNC per carotid plaque.Interreader agreement for the three MR readers was good, with an intraclass correlation coefficient (ICC, 95% confidence interval [CI]) of 0.72 (0.57–0.83). All three MR readers on average found a larger LRNC in the symptomatic group of patients, although this was not statistically significant. The mean LRNC score was 116 ± 129 and 59 ± 62 for symptomatic and asymptomatic patients, respectively (P = 0.13). Symptomatic patients showed wide ranges in LRNC scores (0–424), while the range was much lower in the asymptomatic group (0–170).Single-sequence T1w TFE may be a promising technique to study atherosclerotic plaque at risk of stroke. Larger studies are warranted to confirm these promising results. J. Magn. Reson. Imaging 2008;27:1356–1361. © 2008 Wiley-Liss, Inc.