Objectives: The differences between initial and recurrent stroke plaques are not defined. Hence, a nested case–control study was conducted to evaluate the association of stroke recurrence with the echogenic characteristics of carotid plaques in patients with ischaemic stroke. Methods: One hundred and four patients with 1-year recurrent acute ischaemic stroke were enrolled and compared with 104 control patients (first-time ischaemic stroke) matched for age, gender, stroke severity and treatment allocation. Based on the Mannheim Carotid Intima-Media Thickness Consensus (2004– 2006), the number of carotid plaques and echogenicity between the two groups of patients were compared. Results: As compared to patients with first-time stroke, those with recurrent stroke showed significantly higher prevalence of heart disease (13.46 vs 28.85%, P50.0066) and presence of intracranial stenosis (55.77 vs 89.90%, Pv0.0001). During the 1-year follow-up, patients with recurrent stroke had a significantly higher rate of unstable plaques (80.41%) than patients with first-time stroke (64.21%, P50.036). Also, patients with recurrent stroke had a significantly larger number of plaques than patients with first-time stroke (P50.0152). Multivariate conditional logistic regression analysis (after adjustment for heart disease and intracranial stenosis) identified an association between 1-year stroke recurrence and the presence of unstable plaques (hazard ratio 3.077; 95% CI: 1.133–8.355). Conclusion: Stroke recurrence is related to advanced atherosclerosis defined by carotid plaque and its characteristics. © W. S. Maney & Son Ltd 2015.