To investigate the correlation and the clinical significance between the peripheral serum long non-coding RNA (lncRNA) X-inactive specific transcript (XIST) and microRNA (miR)-92a levels and neurological impairment severity in patients with first-onset acute cerebral infraction (ACI). Methods: Seventy patients with ACI were enrolled in the study as the infarction group, and 48 healthy cases were chose as the control group. The National Institutes of Health Stroke Scale Score (NIHSS) was used to assess the severity of neurological impairment in ACI patients, and those with NIHSS <7 were placed into the minor infarction group and those with NIHSS≥7 into the severe infarction group. Serum lncRNA XIST and miR-92a levels were measured at 48 h and/or 14 d after stroke onset, and results were compared between patients of different groups. Pearson correlation and logistic regression analyses were used to evaluate the relationship between lncRNA XIST and miR-92a levels and NIHSS scores. Results: At 48 h after stroke onset, the serum levels of lncRNA XIST were lower and that of miR-92a were higher in infarction group patients compared to those in control group patients (both P<0.05); furthermore, the serum levels of lncRNA XIST in the severe infarction group were lower than that in the minor infarction group while the miR-92a levels in the severe infarction group were higher than that in the minor infarction group (both P<0.01). Compared to 48 h after stroke onset, the lncRNA XIST levels increased while miR-92a levels decreased at 14 d post-stroke (both P<0.01). The serum lncRNA XIST and miR-92a levels in ACI patients were negatively and positively correlated with NIHSS scores, respectively (both P<0.01). Both lncRNA XIST and miR-92a levels were influencing factors of stroke severity in ACI patients. Conclusion: Our results demonstrate a tight correlation between serum lncRNA XIST and miR-92a levels and neurological impairment severity in the early stage of ACI, which may provide a new target for the treatment of ischemic stroke.