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Background: Complex aortic plaque (CAP) is an embolic source and an atherosclerotic marker, for which older age is one of the strongest risk factors. Whether relationship of CAP with cervicocephalic atherosclerotic burden is consistent in different age ranges remains unclear in acute ischemic cerebrovascular disease (AICVD) patients.Methods: AICVD patients ≥45 years old admitted from November 2015 to May 2016 were consecutively enrolled and underwent CT angiography of both cervicocephalic artery and thoracic aorta. CAP was defined as atherosclerotic plaque in the aortic arch proximal to the ostium of the left subclavian with ≥4 mm thickness, ulceration, or mobile components. The burden of cervicocephalic atherosclerosis was determined on atherosclerotic degree (0 to 5) in 7 different arterial segments, measuring both severity and extent. Difference was assessed between CAP group and non-CAP group.Results: In 285 included AICVD patients, 32.6% had CAP, who tended to be ≥65 and have higher atherosclerotic burden scores. The interaction between age ranges (45~64 and ≥65) and cervicocephalic atherosclerotic burden scores were statistically significant (p≤0.001). Among the middle-aged (45~64, n=178), there was no significant difference in traditional risk factors between CAP group and non-CAP group, while extracranial cervicocephalic atherosclerotic burden score was independently related to existence of CAP. Among the elderly (≥65, n=107), triglycerides level was higher (median 1.35mmol/L vs 1.02mmol/L, p=0.025) in CAP group, but atherosclerotic burden scores were not significantly different in univariate and multivariate analysis.Conclusions: Cervicocephalic atherosclerotic burden is significantly associated with presence of CAP in middle-aged, but not elderly AICVD patients. Assessment of the aortic arch in middle-aged AICVD patients may better help identify the precise cause of their stroke and delineate their overall vascular risk.