Imaging should be included in the workup of dementia patients and is mandatory for the diagnosis of vascular dementia (VaD). MRI is the preferred imaging modality and should include axial T2 and FLAIR, preferably accompanied by a 3D T1-weighted sequence in clinical trials to determine white-matter lesions, infarcts, lacunes, and atrophy. Gradient echo images are needed for microbleeds. Diagnostic criteria should be operationalized and validated visual rating scales are available. In clinical trials, standardized acquisition protocols and central data analysis are mandatory. More work is needed to determine the natural progression in VaD and the possible use of MRI-based outcome measures.