OBJECTIVES: Patients with a recent transient ischemic attack (TIA) or minor ischemic stroke who receive medicines have a 10-year risk of about 16% for any recurrent stroke. Non-invasive molecular imaging technologies are currently being developed to improve individual stroke risk prediction. We estimated the potential lifetime cost-effectiveness of a novel imaging test for stroke prediction in an early stage of development. METHODS: Decision modelling was used to estimate the potential value of an add-on test that could identify which patients with a recent TIA or minor ischemic stroke should undergo surgery instead of receive medicines. The comparator was patient management according to Dutch guidelines. Test sensitivity and specificity were varied from 0-100% and its cost was set at €350. Different age- and gender-specific subgroups were examined to see how much cost-effectiveness varied. RESULTS: A perfect add-on test (100% sensitivity and specificity) for 60-year-old men appears to be cost-effective versus Dutch guidelines, with an estimated 0.61 QALY gain, €3,986 cost increase, and an incremental cost-effectiveness ratio (ICER) of €6,534/QALY gained. A test with sensitivity=60% and specificity=100% increases both health (0.14 QALYs) and costs (€2,888), resulting in an ICER of €20,338/QALY gained. Similarly, a test with sensitivity=100% and specificity=60% increases both health (0.29 QALYs) and costs (€5,784), resulting in an ICER of €19,946/QALY gained. CONCLUSIONS: An imaging test that improves risk prediction and therefore treatment decisions for patients with a recent TIA or minor ischemic stroke has the potential to optimize cost-effectiveness by reducing the risk of recurrent stroke. However, reduced sensitivity or specificity of the test reduces its cost-effectiveness versus the Dutch guidelines. Developers must consider if the minimum level of accuracy required to be cost-effective is close to the maximum capability of the test. Model-based analyses are valuable in facilitating decisions about investments in the further development of a test.