Abstract: Objective To investigate the relationship between carotid artery stenosis (CAS) and imaging markers of cerebral small vessel disease (CSVD), and to explore the potential value of CAS in predicting total CSVD burden. Methods A total of 310 CSVD patients who were admitted to Department of Neurology at the Third Hospital of Hebei Medical University between September 2022 and December 2023 were enrolled. According to the degree of CAS, the patients were divided into two groups: a non-CAS or mild CAS group (stenosis <50%) and a moderate-to-severe CAS group (stenosis ≥50%). Clinical data and imaging findings were collected to assess the total CSVD burden. Univariate and multivariate logistic regression analyses were used to examine the relationships between CAS and CSVD imaging markers, as well as total CSVD burden. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of moderate-to-severe CAS for total CSVD burden. Results Compared with the non-CAS or mild CAS group, the moderate-to-severe CAS group showed significant increases in older patients, high-sensitivity C-reactive protein (hs-CRP), as well as male percentage, diabetes history, smoking history, alcohol consumption, lacunar infarction (LI) percentage, moderate-to-severe enlarged perivascular space (EPVS) percentage, cerebral microbleed (CMB) percentage, moderate-to-severe white matter hyperintensity (WMH) percentage, and moderate-to-severe total CSVD burden (P<0.05). Multivariate logistic regression analysis indicated that moderate-to-severe CAS was an independent risk factor for LI, CMB, WMH, and moderate-to-severe total CSVD burden (P<0.05); moderate-to-severe CAS, age, smoking history, and hypertension were independent risk factors for moderate-to-severe total CSVD burden (P<0.05). ROC curve analysis showed that the area under the curve (AUC) for predicting moderate-to-severe CSVD burden using age, moderate-to-severe CAS, and the combination of age and moderate-to-severe moderate-to-severe CAS were 0.710 (95%CI: 0.653~0.767, P<0.001), 0.606 (95%CI: 0.544~0.668, P=0.001), and 0.748 (95%CI: 0.694~0.802, P<0.001), respectively. Conclusions Moderate-to-severe CAS exacerbates total CSVD burden and may serve as a potential predictor of moderate-to-severe CSVD burden.