A 2-month-old male patient weighted 3 kg presented clinically by respiratory distress (sarnat stage II–III). Conventional MRI (A, B) Axial T2 flair images show high signal intensity in periventricular area (PVL) (red arrows), absent PLIC signal denoting poor myelination (black arrow), Indistinct grey white matter differentiation (blue arrows). Multivoxel MRS (C) and Spectrum (D) long TE 144 show decreased NAA peak with increased of CHO peak, also Multivoxel MRS (E) and spectrum (F) short TE 35 show marked increased lac peak. Lac/Cr at basal ganglia & thalamus ratio 3.67 Lac/Cr > 1.5 indicating severe HIE (grade III). Outcome….. Atonic cerebral palsy….. Died.