Perivascular adipose tissue (PVAT) of the carotid artery is a specialized type of adipose tissue closely adjacent to the arterial adventitia, possessing unique anatomical and functional characteristics. Unlike ordinary adipose tissue, PVAT releases a variety of bioactive molecules through endocrine and paracrine mechanisms, interacting with neighboring vascular wall cells and participating in the regulation of local inflammatory responses and vascular homeostasis. The inflammatory status of PVAT is closely associated with the formation, progression, and vulnerability of carotid atherosclerotic plaques, while also playing a significant role in the development and progression of cerebrovascular diseases. In recent years, with the rapid advancement of imaging technologies, non-invasive assessment of PVAT's inflammatory status has become feasible. The application of these technologies provides new tools for the early identification of high-risk patients with cerebrovascular diseases and holds promise for optimizing preventive strategies and personalized treatment. This article systematically reviews the pathophysiological mechanisms of carotid PVAT, the latest advances in imaging assessment techniques, and their clinical application value.