The main hallmarks of human hippocampal sclerosis are neuronal loss and gliosis; reductions in microvasculature labeling in the cornu Ammonis 1 in this condition have been detected using alkaline phosphatase histochemistry. To determine whether the reduction in alkaline phosphatase activity is coupled with a loss of blood vessels,we examined the volume fraction occupied by blood vessels in toluidine blue-stained hippocampal sections from 24 epilepsy patient resections (19 with hippocampal sclerosis, 5 without hippocampal sclerosis) and 5 normal autopsy controls. Light and electron microscopy and immunohistochemistry were used to determine the distribution of collagen Type IV in relation to the fine structure of the hippocampal microvascular network. We found a consistent and highly significant loss of microvessels in the sclerotic hippocampal cornu Ammonis 1 field; a variety of vascular alterations including spinelike protrusions, disruptions, and atrophic branching, were observed in the remaining blood vessels. We suggest that blood vessel alterations are an additional pathological hallmark of hippocampal sclerosis associated with temporal lobe epilepsy and that they may relate to the pathogenesis of this condition.