Abstract To investigate the ability of super-resolution microcirculation imaging in identifying high-risk histologic transformation (HT) regions, directing the targeted biopsies, and promising timely chemotherapy escalation and outcome improvement. Initially, a retrospective analysis (January 1, 2018–January 1, 2022) of indolent follicular lymphoma (FL) or aggressive diffuse large B cell lymphoma was conducted to identify imaging-based markers of distinguishing aggressive lymphoma from indolent lymphoma. Subsequently, the prospective research consecutively enrolled histologically confirmed FL patients between February 1, 2022, and May 31, 2024, to validate the diagnostic performance of these investigated indicators in differentiating aggressive transformed FL from FL. Diagnostic performance and the diagnostic consistency associated with time were assessed. A total of 132 participants were enrolled: 52 (age 53 years ± 14 [SD]; 34 males) in the retrospective cohort for development and 80 (age 55 years ± 12 [SD]; 34 males), including 10 initial biopsy-confirmed HT, in the prospective cohort for validation. Super-resolution microcirculation imaging demonstrated excellent sensitivity (100%; 95% CI 69.15–100%) and specificity (97.14%; 95% CI 90.06–99.65%) for HT detection, with minimal risk of missed lesions at initial diagnosis. This technique shows potential in early HT detection, facilitating timely chemotherapy escalation and reducing the need for repeat biopsies.