Objective <p>This study investigated the diagnostic value of magnetic resonance angiography (MRA) combined with serum ischaemia-modifier albumin (IMA) testing in predicting secondary cerebral infarction (CI) following transient ischemic attack (TIA).</p> Methods <p>All TIA patients underwent MRA and IMA level assessments, along with ABCD² scoring (a TIA risk stratification tool). Patients were categorized into secondary CI and non-CI groups based on the occurrence of CI within a 90-day follow-up period. Vessel stenosis, serum IMA levels, the predictive value of MRA and IMA levels for secondary CI after TIA, and the independent factors associated with secondary CI in TIA patients were analyzed.</p> Results <p>The high-risk and intermediate-risk groups showed a higher proportion of moderate-severe vessel stenosis and elevated IMA levels compared to the low-risk group, with IMA levels significantly higher in the high-risk group than in the intermediate-risk group (<i>P</i> &lt; 0.05). The secondary CI group exhibited a greater proportion of moderate-severe vessel stenosis and higher IMA levels compared to non-CI group (<i>P</i> &lt; 0.05). The combined predictive model using MRA and IMA demonstrated a significantly higher area under the curve (AUC = 0.908) compared to MRA alone (AUC = 0.798; z = 3.083, <i>P</i> = 0.002), but only slightly higher than IMA alone (AUC = 0.875; z = 1.226, <i>P</i> = 0.220). Independent factors associated with secondary CI included advanced age, moderate-severe vessel stenosis, ABCD² scores, and elevated IMA levels (OR &gt; 1, <i>P</i> &lt; 0.05).</p> Conclusion <p>Changes in MRA and IMA levels were correlated with disease severity in TIA patients. MAR combined with serum IMA demonstrated high predictive efficacy for secondary CI after TIA, making it a valuable tool for CI risk assessment. Independent factors associated with secondary CI included advanced age, moderate-severe vessel stenosis, intermediate-high-risk ABCD² scores, and elevated IMA levels.</p>