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Introduction Hemorrhagic transformation (HT) remains a common and clinically significant complication following successful endovascular thrombectomy (EVT) for large vessel occlusion, contributing to morbidity and mortality. Transcranial Doppler (TCD) provides a non-invasive, real-time bedside assessment of cerebral hemodynamics; however, its role in detecting post-reperfusion hyperemia and its association with subsequent HT is not well defined. We evaluated the relationship between early post-EVT TCD hyperemic parameters and hemorrhagic transformation detected on post-procedural neuroimaging using standardized classification criteria.Methods We identified 31 patients presenting with acute ischemic stroke who underwent EVT achieving at least TICI 2b reperfusion without intravenous tenecteplase. All patients were admitted to neurocritical care and managed post-thrombectomy with individualized systolic blood pressure targets, all overall remaining below 220 mmHg. Comprehensive TCD examinations were performed within 48 hours following EVT. Post-reperfusion hyperemia was defined by one or more of the following criteria: ipsilateral peak systolic velocity (PSV) ≥118 cm/s, ipsilateral-to-contralateral PSV ratio >1.2, or ipsilateral middle cerebral artery (MCA) mean velocity ≥30% higher than the contralateral side. Vessel insonation and window selection followed established practice standards. Hemorrhagic transformation was assessed on post-procedural CT head or MRI and classified according to ECASS III criteria. Demographics, vascular risk factors, procedural characteristics, and baseline imaging parameters, including ASPECTS, were collected.Results The cohort had a mean age of 73 years, with 48% female patients. Ethnic distribution included 55% White, 13% Black, 22% Hispanic/Latino, and 10% Asian. Median admission NIHSS was 13, and baseline ASPECTS ranged from 4 to 10. Mean systolic blood pressure on arrival was 151 mmHg, with mean blood glucose of 132 mg/dL, HbA1c of 5.8%, and platelet count of 242 ×10 9/L. Occlusion sites included M1 (32%), M2 (42%), tandem lesions (10%), isolated ICA (10%), and basilar artery occlusions (6%). Adjunctive intracranial stenting with intravenous Integrilin and intra-arterial agents, including intra-arterial tPA, was required in 10% of patients. Final reperfusion grades were TICI 2b in 29%, 2c in 14%, and 3 in 48%; 3% each underwent 192b, 1→2c, and 2c→3 transitions. Hypertension was present in 81%, while diabetes and smoking history were noted in 42% and 48%, respectively. TCD was performed within ≤6 hours in 26%, >6-12 hours in 14%, >12-24 hours in 42%, and >24 hours in 9%. Hyperemic TCD parameters associated with HT were observed in 3% with ipsilateral PSV ≥118 cm/s alone, 29% with ipsilateral PSV/contralateral PSV ratio >1.2 alone, and 26% with ipsilateral MCA velocity ≥30% higher than the contralateral side alone. Additionally, 23% of patients meeting both ipsilateral PSV/contralateral PSV ratio >1.2 and ipsilateral MCA velocity ≥30% criteria developed HT. No deaths were reported.Conclusions In this single-center experience, TCD evidence of post-reperfusion hyperemia correlated with hemorrhagic transformation in a subset of EVT patients. These findings suggest that early post-thrombectomy TCD may serve as a practical, non-invasive tool for identifying patients at increased risk of hemorrhagic complications. Larger multicenter studies are warranted to validate hyperemia thresholds and determine whether TCD-guided hemodynamic strategies can mitigate post-EVT hemorrhagic transformation.Disclosures S. Vyas: None. Z. Singh: None. T. Snyder: None. S. Scarpiello: None. J. Haimi: None. U. Panchal: None. N. Gadallah: None. P. Sharma: None. H. Zacharatos: None. B. Jankowitz: None.