This study aimed to identify the true ICA tandem occlusions and screen suitability for endovascular recanalization using High-resolution vessel wall imaging (HR-VWI). Patients without blood flow signal in the ICA on MRA who underwent both HR-VWI and DSA was included, and classified into the 4 categories. The suitability for recanalization of occlusion vessels was evaluated. The study showed that about half of patients with an apparent tandem ICA occlusion on DSA, the arteries were, in fact, patent or focal occlusion on VWI. VWI would enable superior identification the true ICA tandem occlusion than DSA.