Proton magnetic resonance spectroscopy (¹H MRS) was evaluated for distinguishing between radiation necrosis and recurrent glioma in 11 patients after high-dose radiotherapy. Six patients had a histological diagnosis of recurrent glioma. Four patients had a histological diagnosis of radiation necrosis and one had a clinical course consistent with the diagnosis of radiation necrosis. ¹H MRS showed cases of radiation necrosis had two characteristic ¹H MRS patterns: markedly increased lactate/creatine and phosphocreatine (Cr) ratio and decreased choline-containing compounds/Cr ratio compared to that of recurrent glioma; or all the major metabolites were completely diminished. The N-acetyl aspartate signal was not helpful for differential diagnosis. ¹H MRS is a potentially useful method for differentiating tumor recurrence from radiation necrosis in patients treated for malignant glioma.