Proton MR spectroscopy has greatly enhanced our understanding of the in vivo pathophysiology of ischemic cerebrovascular disease. This article focuses on 1H MR spectrum changes in the setting of cerebral ischemia and infarction and shows how proton spectroscopy has improved our understanding of these disease processes. The role of 1H MR spectroscopy in cerebral ischemia without infarction, hypoxia-ischemic encephalopathy, and vascular dementia are also reviewed.