Purpose <p>The choroid plexus (CP) plays an interactive role in diverse pathophysiological mechanisms of cerebral small vessel disease (CSVD). We aimed to explore whether the CP has specific imaging or clinical consequences in CSVD by itself.</p> Methods <p>A total of 90 patients with CSVD and 31 healthy controls (HCs) who underwent multiparameter MRI and neuropsychological tests, were retrospectively evaluated. The CP of the lateral ventricles was automatically segmented and manually corrected. The normalized CP volume, susceptibility and perfusion information of CP, and the diffusion tensor image analysis along the perivascular space (DTI-ALPS) index relating to glymphatic efflux were obtained. Partial correlation and multiple linear regression analyses were used to assess the relationship between CP and disease severity and CSVD-related cognitive decline.</p> Results <p>Patients with CSVD had greater CP volume, lower susceptibility, reduced perfusion, and smaller DTI-ALPS indices (all <i>p &lt; 0.05</i>). CP volume was correlated with white matter hyperintensities, lacunes, and CSVD burden (<i>r = 0.237</i>, <i>p = 0.028</i>; <i>r= 0.228</i>, <i>p = 0.034; r = 0.320, p= 0.003</i>). CP volume and perfusion showed correlations with specific cognitive domains (<i>all p &lt; 0.05</i>), including memory, attention, and visuospatial functions. Interestingly, the susceptibility and arterial transit time of CP were related to DTI-ALPS in HC group (<i>β = 0.542,p= 0.047; β=-0.605,p = 0.015</i>), while the correlation vanished in CSVD group.</p> Conclusion <p>The CP showed structural and functional abnormalities, which was related to CSVD disease severity and cognitive status, highlighting CP-targeted interventions as a potential therapeutic strategy. The uncoupling between CP and DTI-ALPS in CSVD patients suggests disrupted fluid homeostasis, warranting further validation via direct glymphatic imaging.</p> Graphical Abstract <p></p>