We studied the clinicopathologic findings in four hypertensive patients with multiple leukomalacia, demyelinated lesions, and lacunar state. Only one patient had clinical evidence of dementia. The periventricular watershed infarcts were attributed to transient episodes of cardiac failure in brains with a compromised circulation in the territory of the deep perforating branches. These observations suggest that Binswanger encephalopathy does not differ from multi-infarct dementia.