To investigate the predictive value of acute brain lesions (ABLs) for the clinical outcomes and delayed encephalopathy after acute carbon monoxide poisoning (DEACMP). This is a retrospective cohort study, patients with acute carbon monoxide (CO) poisoning were divided into the ABLs group and non-ABLs group. Outcome measures included clinical cure, favorable prognosis, and the incidence of DEACMP. Multivariate logistic regression analysis was used to identify independent predictors of clinical outcomes, and subgroup analyses were performed to clarify the impact of ABLs on clinical outcomes. Multivariate analysis showed that ABLs (clinical cure: adjusted odds ratio [aOR] 0.35, 95