Objective: To determine the diagnostic accuracy of 1H- magnetic resonance spectroscopy imaging findings in predicting neurodevelopmental abnorma-lities in term neonates having respiratory distress, using clinical neurological examination as reference standard. Study Design: Cross sectional validation study. Place and Duration of Study: Armed Forces Institute of Radiology and Imaging (AFIRI), Pak Emirates Military Hospital, Rawalpindi, from Oct 2017 to Apr 2018. Methodology: A total of 86 patients were included in study. All term neonates suspected of hypoxic ischemic encephalopathy (HIE) referred for magnetic resonance spectroscopy (MRS) meeting our inclusion criteria were enrolled for study acquisition after taking informed consent from attendants. Results: Approximately 47 out of 86 patients suspected to have perinatal asphyxia showed raised lactate peaks (resonating at 1.3 ppm) in both watershed and ganglionic regions and at 6 months neurological evaluation showed significantly delayed neurological development and delayed milestones. Seven (8.1%) patients clinically suspected to have birth asphyxia showed no specific detectable spectral spikes at 1.31 ppm. Twenty six (30.2%) patients presenting with delayed cry but no laboratory evidence of birth asphyxia showed no definite evidence of visualization of lactate peaks. Six (6.97%) patients showed normal magnetic resonance spectroscopy who had clinical, biochemical suspicion of systemic ischemic insult and later on showed retarded neurodevelopment at 6 months of age. Conclusion: Magnetic resonance spectroscopy (magnetic resonance spectroscopy) spectra in patients having high documented clinical and biochemical suspicion of transitory birth asphyxia from any cause, acquired at frontal watershed territory and deep grey matter showed a characteristic spectral resonance of...............