Mass spectrometry imaging (MSI) is a powerful tool for detecting lipids in tissue sections, with matrix-assisted laser desorption/ionization (MALDI) and desorption electrospray ionization (DESI) as its key ionization techniques. In this study, we examine how MALDI compares with state-of-the-art DESI ionization in identifying lipids in heterogeneous samples, specifically atherosclerotic plaques. Carotid plaques (n = 4) from patients undergoing endarterectomy were snap-frozen, stored at −80°C, and then sectioned for MSI analysis and H&E staining. Measurements were conducted using a SYNAPT XS mass spectrometer in positive ion mode, employing MALDI with a 2,5-dihydroxybenzoic acid (DHB) matrix and DESI with a methanol: water (98:2) (v/v) solvent. Our comparison covered spectral profiles, sensitivity, and image quality generated by these two techniques. We found that both MALDI and DESI are highly suitable techniques for detecting a wide range of lipids in atherosclerotic plaque sections. DESI-MSI exhibited higher ion counts for most lipid classes than MALDI-MSI and provided sharper images. MALDI detected larger amounts of ceramide and hexosylceramide species, possibly due to its efficient generation of dehydrated ions. In contrast, DESI showed greater peak intensities of cholesteryl ester and triacylglyceride species than MALDI, consistent with reduced fragmentation. These findings establish the relative merits of DESI and MALDI and demonstrate their complementarity as techniques for lipid research in MSI.