<b><i>Introduction:</i></b> Symptomatic intracranial hemorrhage represents one of the most feared complications of endovascular reperfusion. We aim to describe a series of patients that experienced immediate reperfusion injury with active intraprocedural extravasation within the territory of the deep penetrating arteries and provide real-time correlation with CT “spot sign.” <b><i>Methods:</i></b> This was a retrospective analysis of patients that suffered reperfusion injury with active arterial extravasation during endovascular stroke treatment in two tertiary care centers. <b><i>Results:</i></b> Five patients were identified. Median age was 63 (58–71) years, 66% were male. Median NIHSS was 13.5 (9.5–23.0), platelet level 212,000 (142,000–235,000), baseline systolic blood pressure 152 (133–201) mm Hg, and non-contrast CT ASPECTS 7.0 (6.5–9.0). Two patients were taking aspirin and one had received intravenous thrombolysis. There were three middle cerebral artery M1, one internal carotid artery terminus, and one vertebrobasilar junction occlusion. Three patients had anterior circulation tandem occlusions. Stroke etiology was extracranial atherosclerosis (<i>n</i> = 2), intracranial atherosclerosis (<i>n</i> = 2), and cervical dissection (<i>n</i> = 1). The median time from onset to puncture was 5.5 (3.9–8.6) h. Intravenous heparin was administered in all patients (median dose of 4,750 [3,250–6,000] units) and intravenous abciximab in four. All tandem cases had the cervical lesion addressed first. Four lenticulostriates and one paramedian pontine artery were involved. Intraprocedural flat-panel CT was performed in four (80%) cases and provided real-time correlation between the active contrast extravasation and the “spot sign.” The bailout included use of protamine, blood pressure control, and balloon guide catheter or intracranial compliant balloon inflation plus coiling of targeted vessel. All patients had angiographic cessation of bleeding at the end of the procedure with parenchymal hemorrhage type 1 in one case and type 2 in four. Three patients had modified Rankin score of 4 and two were dead at 90 days. <b><i>Conclusions:</i></b> Active reperfusion hemorrhage involving perforator arteries was observed to correlate with the CT “spot sign” and to be associated with poor outcomes.