Objective: To investigate the effects of edaravone dexborneol combined with mecobalamin on executive function, the evolution of cerebral microbleeds (CMBs) on susceptibility-weighted imaging (SWI), neurological deficits, and activities of daily living in patients with acute cerebral infarction (ACI) after intravenous thrombolysis. Methods: A total of 110 ACI patients who underwent thrombolysis in our hospital from January 2022 to December 2024 were enrolled and randomly divided into a control group and an observation group, with 55 cases in each group. During the study, 2 cases were excluded, leaving 55 cases in the control group and 53 in the observation group who completed the study. The control group received standard treatment, while the observation group received edaravone dexborneol injection and mecobalamin tablets in addition to standard treatment. Executive function was assessed using the Trail Making Test (TMT) B-A time and the Stroop Color-Word Test (SCWT) interference effect at baseline, 14 days, and 90 days after treatment. SWI was performed to record the total number of CMBs and the number of new CMBs, and the proportion of patients with new CMBs was calculated. The National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Barthel Index (BI) were also evaluated at each time point. Results: At 14 and 90 days after treatment, the TMT B-A time and SCWT interference effect in the observation group were significantly lower than those in the control group (all P<0.05). Repeated measures analysis of variance revealed significant main effects of time and group, as well as a significant time × group interaction effect for both the TMT B-A time and the SCWT interference effect (all P<0.05), with a greater improvement magnitude in the observation group than in the control group. At 14 and 90 days, the number of new CMBs in the observation group was significantly lower than that in the control group (both P<0.05). Within the control group, the number of new CMBs at 90 days increased significantly compared with that at 14 days (P<0.05), whereas no statistically significant difference was observed within the observation group (P>0.05). At 90 days, the proportion of patients with ≥1 new CMBs in the observation group was significantly lower than that in the control group (P<0.05). At 14 and 90 days, the NIHSS scores in the observation group were significantly lower than those in the control group (both P<0.05). At 90 days, the proportion of patients with an mRS score ≤2 (86.79% vs. 65.45%) and the BI scores in the observation group were significantly higher than those in the control group (both P<0.05). There were no statistically significant differences in the incidence of hemorrhagic transformation or adverse events between the two groups (P>0.05). Conclusion: Ultra-early intervention with edaravone dexborneol combined with mecobalamin can significantly improve executive function and neurological outcomes, attenuate the development of new CMBs, and enhance long-term quality of life in ACI patients after thrombolysis, without increasing the risk of bleeding.