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Background and purpose: Because hemorrhagic transformation (HT) is associated with morbidity and mortality, we need a better understanding of the factors that predict HT after ischaemic stroke. HT is a well-known factor that limits the use of thrombolytics and it negates the effect of treatment. This study investigated whether a high serum ferritin level is associated with HT in acute ischaemic stroke. Methods: Seven hundred and fifty-two consecutive patients with acute ischaemic stroke within 24 h after a vascular event were enrolled. HT was diagnosed using magnetic resonance imaging (MRI) or computed tomography (CT) and the HT was classified into hemorrhagic infarction (HI) type 1, 2 and parenchymal hematoma (PH) type 1, 2. HT was also classified into no HT, asymptomatic HT, minor symptomatic HT (sHT), and major sHT. Results: Computed tomography or MR showed HT in 90 patients (HI in 58 and PH in 32; asymptomatic in 53, minor symptomatic in 23 and major symptomatic in 14). The ferritin levels were higher in the patients who developed HT, PH and sHT. After adjustment for confounding variables, multivariate analysis showed that a high ferritin level remained an independent predictor of HT in the patients with acute ischaemic stroke ( P < 0.001). Serum ferritin levels higher than 171.8 ng/ml were independently associated with sHT. Conclusions: This study suggests that a high ferritin level is an important predictor of HT, PH, and sHT in patients with acute ischaemic stroke. Lowering the ferritin level with iron-modifying agents or using free radical scavengers could be helpful to prevent HT in ischaemic stroke. [ABSTRACT FROM AUTHOR]