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Cerebral ischemic stroke (CIS) leads to high mortality and disability due to cerebrovascular obstruction. Current therapeutic approaches such as thrombolysis have limitations, and many patients suffer from long-term functional impairments, so new treatment strategies are urgently needed. Both low-intensity pulsed ultrasound (LIPUS) and mesenchymal stem cell-derived exosomes (MSC-EXOs) have demonstrated some therapeutic potential for CIS, but their efficacy is less pronounced when used alone. Therefore, this study aims to evaluate whether the combination of MSC-EXOs and LIPUS exerts an additive effect in the treatment of cerebral ischemic stroke. Adult rats subjected to middle cerebral artery occlusion (MCAO) were randomly assigned to sham, MCAO, MSC-EXO, LIPUS, or combination groups. Outcomes were assessed using the modified Neurological Severity Score (mNSS), corner and Y-maze tests, histological staining (HE and immunofluorescence), transmission electron microscopy (TEM), and quantitative real-time polymerase chain reaction (q-PCR). The combination group showed notable improvements in neurological function, with the highest proportion of cluster of differentiation 31 (CD31)/alpha-smooth muscle actin (α-SMA)/doublecortin (DCX)-positive immunofluorescence area, up-regulation of circular RNA SCMH-1(circSCMH-1), and the best restoration of synaptic ultrastructure. Compared with MSC-EXOs or LIPUS alone, the combined treatment appeared to have an additive effect, supporting neurovascular regeneration and functional recovery after cerebral ischemic stroke.