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Background and significance: Intracranial cerebral atherosclerosis (ICAS) is closely associated with risk of cerebrovascular diseases, especially in Asian populations. Obstructive sleep apnea (OSA) is associated with systemic atherosclerosis, but it is not clear whether OSA is an independent risk factor of ICAS. We aimed to investigate the association between ICAS and apnea-hypopnea index (AHI), representing severity of OSA, in suspected OSA patients.Methods: We included 142 patients who suspected OSA from Ewha Sleep Center who underwent brain MR angiography (MRA) and polysomnography (PSG). We also investigated the presence and burden of ICAS on MRA and AHI on PSG.Results: The mean patient age was 59.7 ± 13.1 years, and 54.2% (77/142) were male. The mean AHI was 19.8 ± 20.9, and 17 patients (12.0%) had ICAS. Higher AHI was noted in patients with ICAS compared to those without ICAS (38.2 ± 27.1 vs. 17.3 ± 18.7, p = 0.023). The burden of ICAS was positively correlated with severity of OSA (p for trend = 0.013)(Figure 1). In multivariable binary logistic analyses, after adjusting for age, sex, hypertension, hyperlipidemia, smoking, arousal index and minimum SaO2, severe OSA was independently related with presence of ICAS (odds ratio (OR): 14.05, 95% confidence interval (CI): 1.28 - 153.64, p = 0.030). Likewise, in multivariable ordinal logistic regression analyses, severe OSA was marginally associated with burden of ICAS (OR: 8.47, 95% CI: 0.74 - 95.77, p = 0.084).Conclusion: Our findings suggest that severe OSA is associated with presence of ICAS in patients with suspected OSA.