Background: Sickle cell disease (SCD) presents a formidable healthcare challenge, with stroke being a significant complication. While transcranial Doppler ultrasound (TCD) is the gold standard for stroke risk assessment, its availability is often limited by resource constraints. This study investigates the platelet-neutrophil ratio (PNR) as a cost-effective and accessible alternative for stroke risk assessment in SCD patients. Methods: We conducted a retrospective study of 144 SCD HbSS children at Children’s National Hospital, Washington DC, USA. TCD values were categorized as normal, conditional, or abnormal. PNR was calculated from routine blood tests. Statistical analyses were performed to evaluate the association between PNR and stroke risk. Results: PNR values varied significantly across stroke risk categories: 83.83 (58.15-127.65) for normal, 75.69 (64.89-88.6) for conditional, and 62.57 (28.12-64.47) for abnormal (p = 0.031). After adjusting for age and hydroxyurea intake, a unit increase in PNR was significantly associated with a decreased stroke risk (OR = 0.975, 95% CI: 0.953-0.998, p = 0.0345). PNR demonstrated superior discriminative performance for stroke risk compared to neutrophils and platelets, with AUC values of 0.81, 0.57, and 0.19, respectively. Multivariate analysis confirmed that higher PNR was independently associated with a reduced likelihood of abnormal TCD values (OR = 0.975, 95% CI: 0.953-0.998, p = 0.0345). Conclusion: Our study highlights the potential of the platelet-neutrophil ratio (PNR) as a promising, cost-effective, and accessible alternative for stroke risk assessment in SCD management, offering a more equitable healthcare solution.