The augmentation index (AIx) is a measure of pulse wave reflection from peripheral muscular conduit arteries, and is assumed to increase with stiffened arteries. A white matter lesion (WML) is generally regarded as a chronic ischemic lesion, which is associated with cerebral small-vessel arteriosclerosis. The aim of this study is to elucidate the effect of pulse wave reflection on the brain. Carotid AIx was measured in a total of 205 neurologically normal adults. The correlations between AIx and WML were investigated. Two categories of WML were evaluated, periventricular hyperintensity (PVH) and deep and subcortical white matter hyperintensity (DSWMH). On univariate analysis, AIx was significantly correlated with the grades of PVH and DSWMH (P¼0.0001, respectively). On multivariate analysis, AIx was correlated with PVH and DSWMH, independent of other risk factors such as age or blood pressure. Pulse wave reflection from small vessels may influence the genesis of WML. Keywords: augmentation index; endothelial dysfunction; pulse wave velocity; white matter lesion INTRODUCTION White matter lesions (WMLs) have been reported to be a predictive factor in vascular dementia 1-4 and stroke, 5-7 and are generally regarded as chronic ischemic lesions of the brain. Prior attempts to attribute their cause to general arteriosclerosis have been inconclusive. Some reports analyzed the presence of an association between WML and pulse wave velocity (PWV), which is the velocity at which a pulse wave travels between two arterial points and is considered to reflect an advanced stage of arteriosclerosis, but the results were controversial. [8][9][10] Henskens emphasized that an important methodological limitation is the lack of information on carotid wave reflection, and it is difficult to interpret hemodynamic profile from the PWV alone, while the carotid augmentation index (AIx) should be determined as an index of the effect of arterial stiffening on cerebral blood flow. 9 AIx is represented as the ratio of the late systolic component, which consists mainly of the pressure wave reflected back from the peripheral arteries, to the early systolic component in the pulse, and is thought to detect a degree of functional arterial stiffening in the distal muscular conduit arteries. 11-14 Thus, it is hypothesized that the AIx of the carotid artery includes information related to intracranial vascular changes. Based on this hypothesis, we investigated the association between WML and AIx in order to elucidate the effect of pulse wave reflection as an early marker of arterial stiffening on the brain.