Objective: To explore the association between hyperuricemia (HUA) and elevated carotid intima media thickness (cIMT) in adolescents, thereby providing the scientific evidences on the prevention and screening of early cardiovascular damage. Methods: Based on the data from the third follow up survey of "Huantai Childhood Cardiovascular Health Cohort Study" in 2023, a total of 1 155 adolescents aged 12-17 years were included from one nine year school in Huantai County, Zibo City, Shandong Province, using a convenience cluster sampling method. Multivariable Logistic regression models were used to analyze the association between HUA and elevated cIMT in adolescents, and stratified analysis was conducted by sex. Restricted cubic spline (RCS) models were used to examine the dose response relationships between serum uric acid (SUA) levels and elevated cIMT. Results: There was a statistically significant difference in the detection rate of elevated cIMT between the non HUA group (8.48%) and the HUA group (19.06%) ( χ 2=25.23, P <0.05). Multivariable Logistic regression analysis showed that compared with the nonHUA group, adolescents in the HUA group had an increased risk of elevated cIMT [ OR (95% CI )=1.66(1.05-2.63), P <0.05]. Sex subgroup analysis showed similar results in girls [ OR (95% CI )=2.16(1.05-4.34), P <0.05], whereas there was no statistically significant association in boys [ OR (95% CI )=1.47(0.83-2.68), P >0.05]; no significant interaction effect between HUA and sex was observed ( P interaction >0.05). RCS analysis revealed significant J shape non linear dose response relationship between SUA and elevated cIMT in adolescents ( P non linear <0.05); among boys, the result of RCS was similar with that in total population ( P non linear < 0.05 ), yet linear dose response relationship was observed among girls ( P non linear >0.05). Conclusions HUA is associated with the risk of elevated cIMT in adolescents. Monitoring of SUA levels in adolescents, along with targeted interventions, should be conducted to mitigate the risk of adverse cardiovascular events.