Recent advances in the clinical and neuroimaging features of vascular dementia (VAD) versus Alzheimer type dementia (DAT) are described. The lacunar type of VAD, which is often accompanied by silent strokes and a progressive course, is easily confused with DAT. Measurements of cerebral blood flow (CBF) and metabolism (CMR) displayed as brain maps, identify VAD from DAT because of the multifocal and often subcortical nature of the infarcts in VAD, which are strikingly different from the diffuse cortical reductions of CBF and CMR in DAT. Thus, neuroimaging is important for establishing the diagnosis in these two most common forms of dementia in the elderly. A dramatic method for separating VAD from DAT is by utilizing the noninvasive acetazolamide test and xenon contrast CT scanning for measuring the cerebral vasomotor capacitance. In DAT the vasodilator reserve is increased due to the law of initial values. In VAD it is absent or severely blunted so that the differences between the two underlying causes of the dementias become readily apparent.