Hypertension may be a cause of white matter hyperintensity (WMH), but how changes in blood pressure relate to changes in WMH remains unclear. This study aims to clarify the relationship between them.

Clinical data were retrospectively collected from 466 patients who underwent two cranial magnetic resonance imaging examinations with the lesion segmentation toolbox at 11‐ to 14‐month intervals at the Second Affiliated Hospital of Shandong First Medical University. Patients were categorized according to baseline clinical data, including sex, systolic blood pressure (SBP), age, and Fazekas score. WMH volume (WMHv) was measured on T1‐FLAIR and T2‐FLAIR images using MATLAB R2019b software. WMHv before and after magnetic resonance imaging, along with related clinical data, were analyzed using IBM SPSS version 26. Nonparametric independent‐samples tests were used to assess the relationship between WMHv and SBP within each group.

WMH was associated with initial age (r = 0.22, p < 0.05), number of lesions (r = 0.62, p < 0.05), and Fazekas score (r = 0.70, p < 0.05); the second age (r = 0.25, p < 0.05), number of lesions (r = 0.67, p < 0.05), and Fazekas score (r = 0.70, p < 0.05) were also associated with WMH whereas sex showed no significant effect (d ≈ −0.095, p > 0.05). Further analysis revealed that the initial number of lesions (r = 0.16, p < 0.05) and Fazekas score (r = 0.09, p < 0.05) were positively associated with WMHv change; the second number of lesions (r = 0.31, p < 0.05) and Fazekas score (r = 0.22, p < 0.05) were also associated with WMHv change. With fluctuating blood pressure, WMHv changes followed a consistent trend (p > 0.05). Only when the Fazekas score was 1 or 2, did blood pressure changes significantly affect WMHv (Adj. p < 0.05). Pairwise comparative analysis showed that only Fazekas score 1 was statistically significant.

At Fazekas score 1, adjusting SBP may help regulate WMHv. At higher Fazekas scores, SBP change showed no effect on WMHv.