Post-stroke cognitive impairment (PSCI) is one of the most common complications of stroke, seriously compromising patients’ quality of life and rehabilitation outcomes, and has become an urgent challenge in the field of stroke management. MicroRNAs (miRNAs) play pivotal regulatory roles in the pathological processes underlying PSCI, including inflammation, apoptosis, oxidative stress, autophagy, and synaptic plasticity. In recent years, traditional Chinese medicine (TCM) has shown unique advantages and broad prospects in PSCI treatment, exerting its effects through overall regulation, multi-component synergy, and multi-target modulation of miRNA-mediated mechanisms. This review systematically summarizes the mechanism of miRNA in improving cognitive impairment and repair after stroke, and highlights recent progress on TCM-based interventions targeting miRNAs in PSCI. The findings provide a reference for miRNAs as potential biomarkers and therapeutic targets, and offer a theoretical basis for advancing the modernization of TCM in PSCI management.