According to current diagnostic criteria, a definite diagnosis of vascular dementia (VaD) can be reached on pathological grounds by showing the presence of vascular lesions and the absence of degenerative changes exceeding those expected for age. However, while it is commonly accepted that VaD is a group of heterogeneous entities rather than a process with a unique pathological substrate, the spectrum of vessel and parenchyma changes etiologically associated with the clinical syndrome remains basically unidentified. The review of some recent clinical-pathological series shows that different studies have assessed the presence of dissimilar vascular lesions and that, in many cases, no pathological definition was given. This has hindered the clarification of clinical-pathological correlations in the field of VaD. In this scenario, the use of animal models of cerebrovascular diseases may help to elucidate the type of lesions possibly linked with cognitive impairment in humans and might provide insight into some of the pathophysiological mechanisms of vascular cognitive impairment. A consensus is today needed in order to harmonize the pathological examination of vascular lesions in cases of dementia. An ongoing survey aimed at collecting information about the procedures used in different pathological laboratories in the assessment of lesions possibly associated with dementia is finally presented.