Background: Hypoxic-ischemic encephalopathy (HIE) remains a leading cause of adverse neurodevelopmental outcomes. While impaired neurovascular coupling (NVC) coherence has been observed in isolated cases of moderate-to-severe HIE, its broader clinical utility as an early prognostic biomarker for neurodevelopmental trajectories remains poorly defined. Methods: In this large-scale, multi-center prospective cohort study , we enrolled at-risk term and near-term neonates (35–42 weeks gestation) across 29 tertiary hospitals in China (April 2024–May 2025). Participants underwent 6 hours of continuous, synchronized amplitudeintegrated EEG (aEEG) and near-infrared spectroscopy (NIRS) monitoring, initiated within the critical first 6 hours of life. NVC coherence was quantified using wavelet transform analysis. Neurodevelopmental outcomes were evaluated at 6–12 months using the Bayley or Griffiths scales. Results: We identified distinct, severity- and prognosis-dependent frequency patterns. NVC coherence in the 1.5–2 mHz band was significantly decreased in moderate-to-severe HIE. Interestingly , the 0.2–0.5 mHz range exhibited a biphasic response: decreasing in moderatesevere HIE but significantly increasing in mild cases. Crucially , reduced neonatal coherence in the 0.2–0.5 mHz band strongly correlated with adverse neurodevelopmental outcomes at 6–12 months. Conclusion: Early NVC coherence profiling serves as a highly sensitive, non-invasive biomarker for stratifying HIE severity and predicting mid-term neurodevelopment. Frequency-dependent coherence signatures effectively differentiate profound NVC uncoupling in severe injury from active compensatory microcirculatory mechanisms in mild HIE.