To evaluate the proportion of intraplaque hemorrhage (IPH) and its clinical correlation in patients with atherosclerotic stenosis of the middle cerebral artery (MCA) using high-resolution magnetic resonance vessel wall imaging (HRMR-VWI). Methods: We collected clinical and imaging data from patients with moderate to severe stenosis (50%～99%) of the MCA-M1 or M2 segments treated in our hospital from July 2019 to August 2023. IPH was defined as T1 hyperintensity on fat-saturated HRMR-VWI images, with signal intensity>150% of the surrounding muscle tissue. Patients were divided into symptomatic stenosis and asymptomatic stenosis groups based on the presence of ischemic symptoms within the MCA territory within 3 months. The symptomatic stenosis group was further subdivided into artery-to-artery embolism and non-artery-to-artery embolism subgroups according to DWI characteristics. Clinical and imaging data were compared among groups and subgroups. Results: A total of 59 patients were included in the analysis, of whom 14(23.7% ) had IPH in the MCA stenosis lesions. The symptomatic stenosis group comprised 30 patients (50.8%), and the incidence of IPH in symptomatic stenosis patients was 11/30(36.7%), significantly higher than that in asymptomatic stenosis patients [3/29(10.3%)], with a statistically significant difference (P=0.018). Among symptomatic stenosis patients, 11(36.7% ) had artery-to-artery embolism, of whom 7/11(63.6% ) had IPH, a significantly higher incidence than in non-artery-to-artery embolism patients (4/19, 21.1% ), with a statistically significant difference (P=0.047). No significant differences were observed for other factors between the two groups and two subgroups (all P>0.05). Conclusion: The proportion of IPH is higher in symptomatic MCA moderate to severe stenosis patients compared to asymptomatic patients. Moreover, within the symptomatic group, patients with embolic infarction have a higher incidence of IPH. This finding is significant for evaluating the infarction mechanism and stroke risk in MCA stenosis patients.