There are three different pathologic states that produce vascular parkinsonism (VP), including multiple lacunar infarctions in the basal ganglia area, subcortical arteriosclerotic changes (Binswanger's disease), and a single vascular lesion that present a clinical picture indistinguishable from Parkinson's disease. The most prevalent pathologic state of VP in Japan has been shifting from multiple lacunar infarctions in the basal ganglia to Binswanger's disease as a result of changing socioeconomic conditions. Clinical features of VP are symmetrical, predominantly affecting lower extremities, without association with pill-rolling type resting tremor. VP is sometimes accompanied by additional features, such as pyramidal signs, cerebellar signs, pseudobulbar signs, and cognitive impairment. Differential diagnosis of VP from progressive supranuclear palsy, multiple system atrophy type-P, and drug-induced parkinsonism is also discussed.