Purpose: To examine the relationship between hippocampal volumes, 1H magnetic resonance spectroscopy (MRS)-identified hippocampal metabolic function, and verbal memory in patients with unilateral mesial temporal lobe epilepsy (MTLE). Methods: Hippocampal volumes, 1H MRS-derived hippocampal creatine to N-acetylaspartate (Cr/NAA), and verbal memory assessment were obtained preoperatively in 22 patients (six right, 16 left) with EEG-defined unilateral MTLE. Results: Left hippocampal volume correlated significantly with left hippocampal Cr/NAA (r = -0.549, p < 0.01), where-as right volume correlated significantly with right Cr/NAA (r = -0.478, p < 0.05). Verbal memory correlated significantly with left hippocampal Cr/NAA (r = -0.594, p < 0.01), but not with left hippocampal volume or right hippocampal measures. Conclusions: Hippocampal volumes and 1H MRS-derived metabolite ratios are statistically related, but share only a small percentage of variance, suggesting separate but related patho-physiologic processes. Left hippocampal Cr/NAA appears to be more sensitive to verbal memory function than volumes.