<jats:sec> <jats:title>Objective</jats:title> <jats:p>The aim of this article was to evaluate the association of intracranial artery calcification (IAC) with acute downstream ischemic stroke (dAIS)/transient ischemic attack while considering stenosis.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Consecutive stroke computed tomography angiography head/neck examinations from January 2010 to April 2010 were reviewed. Per-vessel IAC and stenosis of greater than or equal to 30% were documented by 2 neuroradiologists. Associations between calcification and dAIS were assessed using multivariate logistic regression, controlling for traditional risk factors and stenosis.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total of 1287 arterial segments from 99 patients were reviewed. Intracranial artery calcification was significantly associated with dAIS (odds ratio [OR], 2.2; <jats:italic toggle="yes">P</jats:italic> = 0.009). This association persisted among nonstenotic arteries, with significantly higher likelihood of dAIS for arteries with IAC than those without (OR, 2.5; <jats:italic toggle="yes">P</jats:italic> = 0.009). However, among stenotic arteries, calcified stenoses had a lower association of dAIS than noncalcified stenoses (OR, 0.55; 95% confidence interval, 0.17–1.8; <jats:italic toggle="yes">P</jats:italic> = 0.33).</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Without concurrent stenosis, IAC is a significant risk factor for dAIS. When stenosis is present, IAC does not increase the association with dAIS. Stenotic and nonstenotic calcifications may represent different disease processes, as represented in the histology literature.</jats:p> </jats:sec>