Leukoaraiosis (LA), an age-related white matter degeneration, is thought to be caused by chronic ischemia. To understand the pathogenesis of LA, we studied the pathology, particularly of the blood vessels, in 186 brains [84 of them with magnetic resonance imaging (MRI)] over the past 10 years. With normal aging, there is gradual thickening of the walls of periventricular veins and venules with collagen subtypes I and III. This venous collagenosis (VC) was increased in brains with LA. Occasionally, LA lesions are not periventricular, but nearer the cortex. In such cases, the most severe VC occurs in the LA lesion rather than near the ventricle. Therefore, LA and VC are not independent degenerative processes coincidentally found near the ventricles, and although damage to the ependyma could be a cause of VC, it cannot be the only cause. Whether VC precedes LA is unknown, but our experience suggests that severe VC is usually accompanied by LA. Arteriolar tortuosity, another age-related vascular pathology, is common in LA. Our thick celloidin sections show three-dimensional views of tortuous arterioles. The tortuosity is much more severe in the white matter and there is considerable loss of parenchyma around them. Staining for collagen IV in the basal lamina reveals tortuous vessels in an "empty bag" that represents the limits of the surrounding parenchyma. These enlarged perivascular spaces correspond to état criblé. The demyelination in LA lesions is accompanied by loss of cells, mostly oligodendrocytes. In studies of apoptosis in LA, we found increased apoptosis within the lesion compared to the surrounding white matter. In conclusion, our studies support the concept that LA results from chronic ischemia due to age-related vascular pathology.