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Using DSA as the reference, the diagnostic accuracy of each MRA technique was independently assessed for ICAO occlusion, CoW anatomy, and collateral pathway patterns. The 4D-MRA acquisitions included time points of 100, 200, 500, 800, 1200, 1600, and 2000 ms. Additionally, the optimal 4D-S-PACK protocol and its capacity to determine CoW flow direction were evaluated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 19 patients with 21 ICAOs were included. Combined 4D-MRA (4D-PACK plus 4D-S-PACK) demonstrated high diagnostic accuracy for detecting ICAO (100.0%) and CoW anatomy (98.2%). In assessing collateral pathways, combined 4D-MRA (sensitivity 95.2%, specificity 100.0%, accuracy 98.2%) outperformed TOF-MRA (sensitivity 85.7%, specificity 86.1%, accuracy 86.0%) and CE-MRA (sensitivity 100.0%, specificity 86.1%, accuracy 91.2%). Using 3 time points (200, 800, and 2000 ms), 4D-S-PACK significantly reduced scan time while maintaining accurate flow direction assessment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Combined non-contrast 4D-PACK and 4D-S-PACK is a promising, non-invasive alternative for comprehensively evaluating ICAO, CoW morphology, and collateral circulation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Advances in knowledge<\/jats:title>\n                    <jats:p>This study establishes that a combined non-contrast 4D-MRA protocol surpasses standard MRA techniques in collateral pathway accuracy, providing a viable, non-invasive alternative to DSA.<\/jats:p>\n                  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