The hippocampus is among the first brain structures to be affected by Alzheimer's disease (AD) pathology. Microstructural alterations within this region have been quantified in vivo using diffusion tensor imaging (DTI), a relatively novel MRI-based technique for mapping diffusion properties of water. Existing evidence indicates that DTI-derived mean diffusivity (MD) of the anterior hippocampus is more predictive than ordinary volumetric indices of the degree of episodic memory impairment in patients with early AD. Thus, altered MD of the (anterior) hippocampus might be highly indicative of hippocampal dysfunction, thereby potentially qualifying this measure as a candidate marker for monitoring progression of AD. Longitudinal studies are needed to confirm this concept. DTI-based assessment of hippocampal microstructure might be also of value for early AD diagnosis and for predicting the course of cognitive decline in subjects at risk for Alzheimer's dementia. Mean diffusivity as microstructural and volume as macrostructural index of hippocampal integrity seem to reflect different, albeit overlapping, aspects of the neurodegenerative process. In contrast, fractional anisotropy is less efficient for quantifying microstructural integrity of the diseased hippocampus in the clinical context. Development of automatic algorithms, providing MD measurements of the hippocampus for routine use, is a task for future studies.