Hypertension is associated with intracranial atherosclerosis (ICAS) and is a leading cause of acute ischemic stroke (AIS). Given sex-differences in the severity of hypertension, we hypothesized sex-differences in ICAS burden among hypertensive patients with AIS. Results show males have significantly higher adjusted total plaque burdens than females. Subgroup analyses show treated hypertensive males with AIS have higher total proximal and bifurcation plaques than treated females. Untreated hypertensive females have significantly higher total proximal and bifurcation plaques compared to untreated males. The results suggest attention to differential hypertension management by sex may be warranted to reduce ICAS burden and AIS risk.