Objective: To determine the feasibility of neck vessel wall imaging technology with three-dimensional variable-flip-angle turbo spin-echo (3D T1w-SPACE) for the detection of carotid atherosclerotic disease before revascularization. Methods: Thirty-one patients who underwent carotid endarterectomy (CEA) and fifty-three patients who underwent carotid stenting (CAS) were enrolled prospectively. Neck vessel wall imaging examination were performed in all patients whilecarotid artery DSA were performed in all CAS patients. Quantitative measurements including stenosis, lesion length, and the presence or absence of plaque ulceration obtained with 3D T1w-SPACE and DSA were independently determined. And images of the 3D T1w-SPACE were compared with corresponding histology to identify major plaque components including intraplaque hemorrhage (IPH), lipid rich necrotic core (LRNC), and calcification (CA). The consistency rate, sensitivity, specificity, positive predictive value and negative predictive value were used to assess diagnostic value. Bland-Altman plots, intraclass correlation coefficient (ICC), and Cohen Kappa were determined. Results: DSA was served as the reference standard. There was an excellent correlation between 3D T1w-SPACE and DSA images in measuring stenosis (r=0.984, P<0.01) and luminal stenosis [ICC=0.98 (95% confidence interval: 0.96-0.99)]. Bland-Altman plots showed that the two examinations were in good consistency in evaluating the extent of stenosis. Sensitivity (89.5%) and specificity (95.1%) was high in 3D T1w-SPACE images compared to DSA for the detection of ulcers. The consistency rate between 3D T1w-SPACE images and histological results for IPH, LRNC and CA detection were 85.7%, 82.1% and 92.9%, respectively. Sensitivity and specificity were 90.0% and 75.0% for IPH; 83.3% and 80.0% for LRNC; 91.3% and 100.0% for CA respectively. However, lesion length measurements by using 3D T1w-SPACE were longer than those measured by using DSA (P<0.01). Conclusion: Neck vessel wall imaging technology with 3D T1w-SPACE is a noninvasive and accurate technique for the diagnosis of carotid artery atherosclerotic disease before revascularization. Copyright © 2019 by the Chinese Medical Association.