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Background: Enlarged perivascular spaces (EPVSs) are commonly detected via magnetic resonance imaging. It is unclear whether EPVSs are associated with cognitive impairment within one month after an acute ischemic stroke (AIS) (i.e., early AIS with cognitive impairment (EAIS-CI)). This study explored the severity and location of EPVSs and their association with EAIS-CI severity and provides clinicians with early warning indicators before the onset of typical clinical symptoms in the Chinese population. Methods: The clinical data of 208 patients (176 AIS patients and 32 controls) were prospectively analyzed using the Montreal Cognitive Assessment Beijing version (MoCA-BJ) score as the primary group criterion and the Mini-Mental State Examination (MMSE) score as a supplementary criterion. When EPVS I as the main EPVS type detected by imaging, the basal ganglia (BG) is the area most severely affected. Statistical analysis was conducted on the relevant clinical data. Results: AIS patients were grouped based on MoCA-BJ scores. Age (p < 0.01), education level (p = 0.02), EPVS I as the main EPVS type (p < 0.01), the number of right-sided BG-EPVSs (p = 0.04), white matter hyperintensities (WMHs) (Fazekas scores: p = 0.02), brain atrophy (global cortical atrophy scores: p < 0.01, Koedam posterior atrophy visual scale scores: p = 0.01, medial temporal lobe atrophy scores: p < 0.01) and AIS lesion volume (p = 0.01) were significantly greater in the EAIS-CI group than in the EAIS without cognitive impairment group. The cognitive domains of attention (p = 0.04) and orientation (p < 0.01) were more closely associated with EPVS I as the main EPVS type. However, multivariate regression analysis did not identify EPVS I as the main EPVS type as the main risk factor for EAIS-CI (p = 0.098). Grouping by MMSE scores revealed that EPVS I as the main EPVS type was linked to low education level (p < 0.01) and was significantly associated with EAIS in individuals with cognitive dementia (p < 0.01). Conclusions: As a result of multiple factors, EAIS-CI is significantly associated with a low education level, BG-EPVS, WMHs, and worsening brain atrophy severity. Imaging markers, such as the severity of BG-EPVS, can assist in the early diagnosis and assessment of EAIS-CI. Clinical Trial Registration: The study was registered with the China Clinical Trial Registry (https://www.chictr.org.cn/), registration number: ChiCTR2000038819.