Sex and gender differences significantly affect the risk, clinical manifestations, and prognosis of acute ischemic stroke (AIS). Overall, men exhibit higher age-standardized incidence rate of AIS, whereas women bear disproportionate burdens of long-term neurological dysfunction and disability in advanced age. This review synthesizes evidence from Global Burden of Disease Study, population-based cohorts and biobanks, randomized controlled trials, and multicenter mechanical thrombectomy studies, and focuses on sex- and gender-related neuroimaging phenotypes of AIS and their implications for reperfusion therapy. Accumulating data indicate that sex- and gender-related brain structure and cerebrovascular imaging characteristics develop gradually before AIS onset and manifest as differences in ischemic core extent, collateral circulation status, and lesion topography during the acute phase. Although there are sex- and gender-related differences in neurovascular anatomy and pathophysiology, the relative efficacy of intravenous thrombolysis and mechanical thrombectomy is generally comparable between men and women when AIS patients are selected using modern imaging criteria and after adequate adjustment for baseline characteristics. These findings suggest that sex and gender alone should not restrict access to reperfusion therapies; however, such differences remain important contextual considerations for imaging interpretation and prognostic assessment. Incorporating sex- and gender-related neuroimaging features into integrated evaluation frameworks may improve AIS patient stratification and facilitate more precise and equitable stroke care.