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Background and Objectives Hemorrhagic infarction (HI), defined as petechial bleeding within infarcted tissue, is frequently considered a benign phenomenon. However, its clinical significance when detected on sensitive MRI prior to mechanical thrombectomy (MT) remains unclear. We aimed to evaluate whether pre-treatment HI is associated with 90-day functional dependence, post-MT parenchymal hematoma (PH), and symptomatic intracerebral hemorrhage (SICH).Methods We performed a retrospective cohort study of consecutive patients with anterior circulation large vessel occlusion undergoing MT at two academic centers between January/2015 and December/2022. Patients with pre-MT T2*-weighted MRI were included. HI was classified (Type I/II) per ECASS-III criteria. The primary outcome was 90-day functional dependence (modified Rankin Scale [mRS] 3-6). Secondary outcomes included ipsilateral PH and SICH. Multivariable Bayesian and frequentist logistic regression models were utilized to adjust for clinical and procedural covariates.Results Among the 479 included patients (median age, 72 years; 46% female; 50% received IV thrombolysis), pre-treatment HI was identified in 25 (5.2%) patients. Functional dependence occurred in 47%, ipsilateral PH in 9.4%, and SICH in 3.1%. In multivariable analysis, pre-MT HI was independently associated with 90-day functional dependence (frequentist aOR 5.95, 95% CI 1.91-18.52, p=0.002; Bayesian OR 6.66, 95% CrI 2.15-24.28). Pre-MT HI also demonstrated a high posterior probability of association with the development of ipsilateral PH (frequentist aOR 2.84, 95% CI 0.84-9.58; Bayesian Pr[OR>1]=0.94) and SICH (frequentist aOR 6.02, 95% CI 1.00-36.11, p=0.049; Bayesian Pr[OR>1]=0.95).Conclusion HI detected on pre-treatment MRI is associated with poor long-term functional outcomes and an increased risk of severe hemorrhagic transformation following MT. While not a contraindication to intervention, pre-treatment HI may serve as a critical biomarker of reperfusion vulnerability and a target for neuroprotective strategies.Disclosures T. Goulart: None. A. Bonkhoff: None. E. Lindgren: None. B. Teasdale: None. A. Das: None. V. Tutino: None. C. Simonsen: None. N. Rost: None.Abstract E-298 Table 1Comparison of clinical and imaging presentation characteristics between patients with and without pre-thrombectomy hemorrhagic infarctionAbstract E-298 Table 2Association between hemorrhagic infarction on pre-treatment MRI and 90-day functional dependence using Bayesian and frequentist logistic regression models