Objective: To determine which vascular pathology measure most strongly correlates with white matter hyperintensity (WMH) accumulation over time, and whether Alzheimer disease (AD) neuropathology correlates with WMH accumulation.Methods: Sixty-six older persons longitudinally followed as part of an aging study were included for having an autopsy and .1 MRI scan, with last MRI scan within 36 months of death. Mixed-effects models were used to examine the associations between longitudinal WMH accumulation and the following neuropathologic measures: myelin pallor, arteriolosclerosis, microvascular disease, microinfarcts, lacunar infarcts, large-vessel infarcts, atherosclerosis, neurofibrillary tangle rating, and neuritic plaque score. Each measure was included one at a time in the model, adjusted for duration of follow-up and age at death. A final model included measures showing an association with p , 0.1.Results: Mean age at death was 94.5 years (5.5 SD). In the final mixed-effects models, arteriolosclerosis, myelin pallor, and Braak score remained significantly associated with increased WMH accumulation over time. In post hoc analysis, we found that those with Braak score 5 or 6 were more likely to also have high atherosclerosis present compared with those with Braak score 1 or 2 (p 5 0.003).Conclusion: Accumulating white matter changes in advanced age are likely driven by small-vessel ischemic disease. Additionally, these results suggest a link between AD pathology and white matter integrity disruption. This may be due to wallerian degeneration secondary to neurodegenerative changes. Alternatively, a shared mechanism, for example ischemia, may lead to both vascular brain injury and neurodegenerative changes of AD. The observed correlation between atherosclerosis and AD pathology supports the latter. Disruption of white matter integrity, frequently observed as white matter hyperintensities (WMH) on T2-weighted MRI sequences, has detrimental effects on cognitive function, motor performance, and functional status in the elderly [1][2][3] and is associated with increased risk of all types of dementia, including Alzheimer disease (AD).4 Furthermore, WMH accumulation over time has been shown to increase risk of cognitive decline. 3,[5][6][7] While the general consensus is that the etiology of white matter accumulation is secondary to small-vessel ischemic changes, [8][9][10][11][12][13] it is not well established whether those with faster WMH accumulation may have contributions from other pathologies. Because accumulation of WMH increases risk of cognitive decline, identifying the pathologic correlates of faster WMH accumulation could potentially guide interventions targeting specific risks for prevention and treatment to preserve cognitive function in the elderly. Furthermore, while there are previous observations supporting a link between cerebrovascular disease (CVD) and AD, 14 it is not clearly established whether WMH progression is associated with neurodegenerative changes of AD. Thus, our aim was to bette...