Objective <p>The aim of this study was to examine the relationship between the sonographic hepatorenal index and stroke risk in patients with nonalcoholic fatty liver disease (NAFLD).</p> Methods <p>From December 2023 to July 2024, 72 NAFLD patients with stroke, 53 stroke-free NAFLD patients, and 54 healthy controls were enrolled in our study. The hepatorenal index was calculated as the ratio of the echo intensity of the liver to that of the renal cortex. The mean brightness values for one region of interest within the right hepatic lobe and the other size-matched region at the same depth of field within the right kidney were obtained with two-dimensional ultrasound and a 1- to 6-MHz convex array probe. Laboratory tests were performed with a Cobas 8000 automatic biochemical analyzer. Univariate and multivariate analyses were adopted to analyze the risk factors for stroke in NAFLD patients.</p> Results <p>NAFLD patients had a greater hepatorenal index than healthy controls did (<i>P</i> &lt; 0.05). Additionally, NAFLD patients with stroke had an even greater hepatorenal index than did those with stroke-free NAFLD (<i>P</i> &lt; 0.001). Multivariate regression analysis further revealed that the hepatorenal index was independently associated with stroke risk in NAFLD patients (β = 8.897, <i>P</i> &lt; 0.001) after controlling for age, body mass index, systolic blood pressure, and serum glucose, total cholesterol, alanine transaminase, and creatinine concentrations. Receiver operating characteristic curve analysis revealed a sensitivity of 62.5% and specificity of 95.3% for the hepatorenal index, with a cutoff value of 1.255 and an area under the curve of 0.80.</p> Conclusion <p>The increased sonographic hepatorenal index could be an independent predictor of stroke development in patients with NAFLD.</p>