Background: In Caucasian patients with acute stroke or transient ischemic attack (TIA) due to symptomatic intracranial atherosclerotic stenoses (ICAS), only limited data on the recurrent stroke rate and its associated risk factors have been reported. In view of the increasing options for endovascular interventions, we sought to investigate the prevalence, risk for recurrent stroke and mortality in these patients. Methods: A total of 304 consecutive patients with acute ischemic stroke or TIA due to 50–99% ICAS were prospectively documented in 19 German stroke centers. In 201 patients (68.1% of the survivors), a central biannual telephone follow-up could assess recurrent stroke and mortality up to a median of 2 years after the index event. Results: An ischemic cerebrovascular event attributable to symptomatic ICAS was found in 2.24% of the consecutively admitted patients. The overall cumulative recurrent stroke rate after admission was 17.9% (95% CI = 13.4–23.5) for the first year and 23.3% (95% CI = 17.8–29.8) over 3 years. After correction for age and sex, only previous stroke (HR = 2.11, 95% CI = 1.14–3.91) and diabetes (HR = 2.41, 95% CI = 1.33–4.37) were significantly associated with recurrent stroke. Conclusion: Although the prevalence of this etiology seems very low in patients admitted to German stroke centers, we found a high risk of recurrent stroke in patients with symptomatic ICAS. Whether endovascular interventions can reduce this high risk needs to be determined in a randomized trial.