Objective To investigate the prognostic value of high-resolution magnetic resonance vessel wall imaging (HRMR-VWI) in patients with cerebral infarction caused by large artery atherosclerosis (LAA).Methods A total of 115 patients with cerebral infarction caused by LAA at the Baoji High-tech Hospital from January 2022 to October 2024 were retrospectively selected. All patients were examined by HRMR-VWI. They were followed up for 3 months and divided into the good prognosis group (74 cases) and the poor prognosis group (41 cases) based on their modified Rankin Scale (mRS) scores at 3 months. The clinical characteristics of the two groups were compared, and the factors independently affecting the prognosis were determined by the multivariable stepwise Logistic regression analysis. The predictive value of HRMR-VWI for the prognosis was analyzed by the receiver operating characteristic (ROC) curve.Results The poor prognosis group had significantly higher age, National Institutes of Health Stroke Scale (NIHSS) scores, homocysteine (Hcy) levels, low-density lipoprotein (LDL) levels, plaque volume, plaque burden, stenosis rate, vascular remodeling index, as well as a higher incidence of intraplaque hemorrhage and lipid-rich necrotic core, compared with the good prognosis group (P < 0.05). In contrast, the fibrous cap thickness in the poor prognosis group was lower than that in the good prognosis group (P <0.05). The multivariable Logistic regression analysis revealed that high NIHSS scores [O^R=4.252 (95% CI: 1.999, 9.042)], high Hcy levels [O^R=1.105 (95% CI: 1.021, 1.196)], large plaque volume [O^R=2.528 (95% CI: 1.522, 4.198)], high plaque burden [O^R=2.913 (95% CI: 1.493, 5.683)], high stenosis rate [O^R=5.220 (95% CI: 1.922, 14.172)], high vascular remodeling index [O^R=1.884 (95% CI: 1.307, 2.714)] and intraplaque hemorrhage [O^R=3.168 (95% CI: 1.393, 7.201)] were all risk factors for poor prognosis in patients with cerebral infarction caused by LAA (P < 0.05). The ROC curve analysis exhibited that the sensitivities of HRMR-VWI parameters, including plaque volume, plaque burden, stenosis rate, vascular remodeling index, intraplaque hemorrhage, and their combination, in predicting patient prognosis were 70.7%, 65.9%, 75.6%, 73.2%, 61.0%, and 90.2%, with the specificities being 74.3%, 70.3%, 73.0%, 68.9%, 75.7%, and 86.5%, and the areas under the curves being 0.792, 0.770, 0.809, 0.790, 0.683, and 0.952, respectively (P < 0.05).Conclusion HRMR-VWI parameters, including plaque volume, plaque burden, stenosis rate, and vascular remodeling index, are independent predictors of prognosis in patients with cerebral infarction caused by LAA. Clinical assessment using HRMR-VWI demonstrates a certain predictive value for outcomes in these patients.