Accumulating evidence highlights the association of calcium characteristics and cardiovascular events, but its role in cerebrovascular stenosis has not been well studied. We aimed to investigate the contribution of calcium patterns and density to recurrent ischemic stroke in patients with symptomatic intracranial atherosclerotic stenosis (ICAS).In this prospective study, 155 patients with symptomatic ICAS in the anterior circulation were included, and all subjects underwent computed tomography angiography. The median follow-up for all patients was 22 months and recurrent ischemic stroke were recorded. Cox regression analysis was performed to examine whether calcium patterns and density were associated with recurrent ischemic stroke.During the follow-up, 29 patients who experienced recurrent ischemic stroke were older than those without recurrent ischemic stroke (62.93 ± 8.10 years vs. 57.00 ± 12.07 years, p = 0.027). A significantly higher prevalence of intracranial spotty calcium (86.2% vs. 40.5%, p < 0.001) and very low-density intracranial calcium (72.4% vs. 37.3%, p = 0.001) were observed in patients with recurrent ischemic stroke. Multivariable Cox regression analysis showed that intracranial spotty calcium, rather than very low-density intracranial calcium, remained an independent predictor of recurrent ischemic stroke (adjusted hazard ratio 5.35, 95% confidence interval 1.32-21.69, p = 0.019).In patients with symptomatic ICAS, intracranial spotty calcium is an independent predictor of recurrent ischemic stroke, which will further facilitate risk stratification and suggest that more aggressive treatment should be considered for these patients.© 2023. The Author(s).