In the elderly, asymptomatic white matter hyperintensities are common on T2-weighted magnetic resonance imaging (MRI). In symptomatic patients, such MRI appearances correlate with varied postmortem findings including demyelination or stroke. What structural correlates underlie the T2 hyperintensities in patients whose lesions are asymptomatic is controversial. Therefore, in order to investigate the underlying metabolism and perfusion in white matter lesions (exhibiting T2 hyperintensity), 13 patients underwent proton magnetic resonance spectroscopy and dynamic gadolinium-DTPA perfusion-weighted MR imaging. N-acetyl aspartate (NA) levels were reduced in the lesions compared with age-matched controls (P = 0.031), implying neuronal/axonal loss. Creatine levels were also reduced (P = 0.001). Choline levels were unchanged in the lesions. Lactate was identified in the lesions of 5 of the 13 patients. Although not statistically significant, perfusion studies exhibited a trend toward lower cerebral blood volumes in patients with high grade extracranial carotid stenosis and lactate-containing lesions. These findings suggest that neuronal/axonal loss underlies the majority of T2-weighted asymptomatic lesions in the older population, and in many cases these changes may be due to chronic ischemia.