Background: The development of transcranial color-coded duplex sonography (TCCS) has resurrected the hope of safe, real time bedside brain imaging beyond childhood. This research provides an overview of the role transcranial color-coded duplex (TCCD) as a predictor of early outcome in acute ischemic stroke. Aim and methods: In this comparative cross-sectional study, we sought to investigate the ability of TCCD to detect early clinical outcome in patients with acute ischemic stroke. 50 CVIS patients were recruited for this study. Extracranial carotid artery duplex and TCCD was done at day 1 and day 7. Assessment of severity of stroke was done based on NIHSS at presentation and day 7. Assessment of outcome at 3 months after onset was done based on Barthel index score (BI) and CVIS recurrence. MCA stenosis and asymmetry was significantly associated with poor outcome. Results: Stenosis was higher in dead cases. However, normal middle cerebral artery (MCA) status was significantly associated with good outcome. Patients with combined MCA+ICA stenosis had significantly higher NIHSS at presentation, at follow up, significantly lower BI than separate intracranial MCA stenosis. In patients with MCA abnormalities, recanalization was significantly associated with higher improvement by NIHSS score, non-significantly associated with lower rate of 3 months CVS recurrence, and no significant association was found between MCA recanalization and BI score outcome. Conclusion: The presence of intracranial MCA stenosis or asymmetry is an independent predictor of poor outcome for stroked patients.