Early prediction of stroke-associated pneumonia (SAP) is significant in clinical practice, as it is frequently challenging due to delays in typical clinical manifestations and radiological changes. The monocyte-to-lymphocyte ratio (MLR) has been proposed as an indicator of systemic inflammation and infection. However, none of these studies have focused on the predictive value of the MLR for SAP. We investigated the predictive value of MLR for SAP and investigated its relationship with disease severity. In this retrospective study, we assessed 399 consecutive patients with acute stroke. SAP was defined according to the modified Centers for Disease Control and Prevention criteria. The severity of pneumonia was rated using the pneumonia severity index (PSI). MLR was calculated by dividing absolute monocyte counts by absolute lymphocyte counts. Among all the patients, SAP occurred in 116 patients (29.1%). White blood cell (WBC), neutrophil, monocyte, and MLR levels in the SAP group were higher than those in the non-SAP group, while lymphocyte levels were lower (p < .05). Multivariable regression analysis revealed that the MLR (OR = 7.177; 95% CI = 1.190-43.292, p = .032) remained significant after adjusting for confounders. The ROC curve showed that the AUC value of MLR for SAP was 0.779, the optimal cutoff value of MLR for SAP was 0.388, with a specificity of 64.7% and sensitivity of 81.3%. The MLR levels were significantly higher in the severe pneumonia group when assessed by PSI (p = .024) than in the mild group. The AUC value of MLR was 0.622 (95% CI = 0.520-0.724, p = .024) in the severe pneumonia group. The optimal cutoff value of MLR was 0.750, with a specificity of 91.0% and a sensitivity of 33.0%. Our study shows that a high MLR is an independent risk factor for SAP and has a predictive value for severe pneumonia in patients with SAP. © 2021 The Authors. Brain and Behavior published by Wiley Periodicals LLC.