Background: The metabolic syndrome (MetS) is a clustering of vascular risk factors that tend to increase the risk of occurrence diabetes mellitus type 2 (DMT2), cardiovascular and cerebrovascular ischemic events. Many studies have shown MetS to have a significant effect on the occurrence of asymptomatic Carotid atherosclerosis and silent brain infarctions (SBI).Objectives: To determine the risk of MetS on asymptomatic Carotid atherosclerosis and SBI in Egyptian patients and to detect their proportion and pattern in MetS patients.Methods: A cross sectional observational study was conducted on 80 Egyptian subjects divided into 2 groups, 50 subjects with MetS and 30 without MetS. All subjects were asymptomatic regarding neurovascular ischemic events [stroke or transient ischemic attack (TIA)]. All subjects underwent complete neurological examination, assessment of diagnostic criteria of MetS, Carotid and transcranial duplex ultrasonography (U/S) and brain MRI.Results: MetS had a significant effect on the development of Carotid atherosclerotic plaques compared to the control group. All plaques caused <50% stenosis. Yet there was no significant difference between both groups regarding isolated elevation of Carotid mean intima media thickness (IMT). Also, MetS had no significant effect regarding the occurrence, distribution of intracranial atherosclerotic disease (ICAD) or the degree of intracranial stenosis (ICS). On the other hand, there was a highly significant difference between both groups regarding SBI. Multivariate analysis revealed abnormal brain MRI findings to be the only independent predictor of MetS.Conclusion: MetS has a significant effect on the occurrence of cerebral large artery (at least partially) and small artery atherosclerosis.