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Background Inflammation plays an important role in the development of ischemic stroke. We hypothesized that inflammation of carotid atherosclerosis, as measured by 18 F-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET), associates with the early recurrent ischemic lesions (ERILs). Methods This prospective study included patients with symptomatic carotid atherosclerosis. ERILs were defined as newly developed ischemic lesions in the territory of symptomatic internal carotid artery stenosis, as detected by follow-up diffusion-weighted imaging (DWI). The patients with and without ERILs were compared in terms of risk factors, inflammatory markers, and FDG uptake on PET. Results Of the 21 patients, 8 had ERILs (38.1%). Compared to the patients without ERILs, those with ERILs had higher FDG uptake (maximum standardized uptake value, 3.07 ± 0.79 vs. 2.17 ± 0.68, p = 0.013) and were more likely to have irregular carotid plaques (100% vs. 38.5%, p = 0.007). Inflammatory markers were not different between the two groups, and also did not correlate with FDG uptake. Conclusions Increased carotid plaque inflammation, as measured by FDG uptake on PET, may be a useful marker for identifying patients with symptomatic carotid atherosclerosis who are at risk of recurrence. [ABSTRACT FROM AUTHOR]