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Objective We aimed to analyze and predict the risk of white matter lesions (WMLs) in hypertensive patients with different traditional Chinese medicine (TCM) syndromes, and to explore the relationship and influencing factors between them. Methods From September 2019 to December 2021, 309 patients were enrolled from the cardiovascular departments of the Affiliated Hospital of Gansu University of Traditional Chinese Medicine according to the inclusion and exclusion criteria, and they were divided into four syndromes: phlegm and blood stasis syndrome, kidney qi deficiency syndrome, liver fire hyperactivity syndrome, and yin deficiency and yang hyperactivity syndrome. Diastolic blood pressure (DBP), homocysteine acid (Hcy), uric acid (UA), and serum cystatin C (Cys C) were measured. The ARWMC and Fazekas scales were used to assess the site, score, and the degree of WMLs (mild, moderate, or severe) in hypertensive patients with different syndromes, and the correlation between risk factors and different syndromes was summarized. Results There were significant differences in DBP, Hcy, UA, and Cys C among different TCM syndrome types (P<0. 05). WMLs were assessed by the Fazekas and ARWMC scales, and there was no significant difference in the distribution of WMLs sites among different syndrome types. There was no significant difference in the Fazekas scores of WMLs, but there was a significant difference in the ARWMC ratings among different syndrome types (P<0. 05). The WMLs Fazekas and ARWMC risk classification analysis of different TCM syndrome types were significantly different (P<0. 05). According to the Fazekas scale assessment, there were differences in WMLs among all of the syndrome types (P<0. 05). Spearman rank correlation analysis showed that the WMLs degree was positively correlated with age, Hcy, Cys C, and UA in the phlegm and blood stasis syndrome group (rs =0. 22, 0. 23, 0. 18, 0. 24, P<0. 05). The WMLs degree was negatively correlated with HUA and HHcy (rs =-0. 19, -0. 21, P<0. 05). The degree of WMLs was positively correlated with UA (rs =0. 48, P<0. 05), and negatively correlated with HUA (rs = -0. 47, P<0. 05). The degree of WMLs in yin deficiency and yang hyperactivity syndrome group was positively correlated with age, HUA, and Cys C (rs = 0. 37, 0. 27, 0. 27, P <0. 05), and negatively correlated with UA (rs = -0. 32, P < 0. 05). The degree of WMLs in the kidney qi deficiency syndrome group was positively correlated with Hcy (rs = 0. 33, P <0. 05), but negatively correlated with HHcy and DBP (rs = -0. 32, -0. 30, P < 0. 05). The phlegm and blood stasis syndrome had more risk factors with a statistically significant difference (P < 0. 05) compared with the liver fire hyperactivity syndrome, yin deficiency and yang hyperactivity syndrome, and kidney qi deficiency syndrome. According to the ARWMC rating, there were differences in WMLs among all syndrome types (P<0. 05). Spearman rank correlation analysis showed that the WMLs degree was positively correlated with UA (rs =0. 57, P<0. 05) and negatively correlated with HUA (rs =-0. 58, P<0. 05) in patients with hypertension and the ARWMC rating. The degree of WMLs was positively correlated with UA (rs = 0. 34, P <0. 05), and negatively correlated with HUA (rs =-0. 44, P<0. 05). The degree of WMLs in the kidney qi deficiency syndrome group was positively correlated with Cys C (rs =0. 26, P<0. 05), and negatively correlated with diabetes mellitus and HUA (rs =-0. 30, -0. 28, P<0. 05). There were more risk factors with statistically significant differences (P<0. 05) in the kidney qi deficiency syndrome compared with phlegm and blood stasis syndrome, liver fire hyperactivity syndrome, and yin deficiency and yang hyperactivity syndrome. Conclusion The phlegm and blood stasis syndrome and kidney qi deficiency syndrome may be TCM syndrome types with higher incidences of WMLs in hypertensive patients. [ABSTRACT FROM AUTHOR]