We performed 4D Flow MRI assessment of arterial pulsation in internal carotid artery stenotic disease (ICS) patients comparing to SPECT with acetazolamide challenge. Twelve patients with unilateral ICS were recruited. The blood flow volumes and the ratio of ΔF (rΔF) was calculated. In the affected-side MCA territory, the ratio of rest cerebral blood flow control (RCBFMCA) and cerebral vascular reserve (CVRMCA) were calculated from SPECT dataset. rΔF was significantly lower in the low CVR group than high group (P=0.008). The 6-min-standard 4D Flow MRI assessment of arterial pulsation in ICS patients can identify misery perfusion.