Purpose <p>To evaluate the value of conventional ultrasound and contrast-enhanced ultrasound (CEUS) in predicting the risk of recurrence in patients with ipsilateral anterior circulation ischemic stroke (ACIS).</p> Methods <p>The clinical, laboratory, and ultrasound data of 295 patients who were hospitalized for their initial ACIS between January 2016 and May 2023 were collected. Based on 6–24 months follow-up results, patients were categorized into two groups: the recurrence group and the non-recurrence group. Differences in clinical characteristics, laboratory tests, and ultrasound findings between the two groups were analyzed.</p> Results <p>Statistically significant differences were observed between the recurrence and non-recurrence groups in terms of age, carotid plaque side, and CEUS grade (<i>P</i> &lt; 0.05). Multivariate analysis identified CEUS grade as an independent risk factor for ACIS recurrence(<i>P</i> = 0.032). A CEUS grade ≥ 2 demonstrated high predictive accuracy for recurrence, with a sensitivity of 91.04%, specificity of 85.09%, and overall accuracy of 86.44%.</p> Conclusion <p>CEUS grade could independently predict the recurrence risk of ipsilateral ACIS, providing valuable insights for the clinical management and prevention of recurrent ipsilateral ACIS in this patient population.</p>