The large pool of cholesterol in the brain is effi ciently isolated from other pools of cholesterol in the body by the effi cient blood-brain barrier (for reviews, see 1, 2 ). In contrast to the lipoprotein-bound cholesterol in the circulation, side-chain oxidized cholesterol metabolites are able to cross the blood-brain barrier and fl uxes of oxysterols have been demonstrated in both directions. We ( 3, 4 ) and others ( 5 ) have shown that about two-thirds of the synthesis of cholesterol in the brain is compensated for by a fl ow of 24S-hydroxycholesterol (24OHC) from the brain into the circulation. We also demonstrated a fl ux of the extracerebral metabolite 27-hydroxycholesterol (27OHC) from the circulation into the brain with a net uptake of this oxysterol ( 6 ). Most of the 27OHC present in the cerebrospinal fl uid originates from the circulation ( 7 ).Despite the substantial uptake of 27OHC by the brain, the levels of this oxysterol in the brain are very low, reaching only 5-10% of the levels of 24OHC ( 3,8 ). The reason for this is a highly effi cient metabolism. We have shown that the end metabolite of 27OHC in the brain is a steroid acid, 7 ␣ -hydroxy-3-oxo-4-cholestenoic acid, and that there is a continuous fl ux of this acid from the brain into the circulation ( 9 ). The nature of this acid as an end metabolite is illustrated by a very substantial accumulation of it in encapsulated brain hematomas ( 10 ). The rate-limiting step in the conversion of 27OHC into the steroid acid appears to be the introduction of a 7 ␣ -hydroxyl group catalyzed by the enzyme oxysterol 7 ␣ -hydroxylase, CYP7B1 ( 9 ). This enzyme is exclusively located in neuronal cells in the brain ( 11 ).Despite the fact that lipoprotein-bound cholesterol does not pass the blood-brain barrier ( 1, 2 ), hypercholesAbstract There is a signifi cant fl ux of the neurotoxic oxysterol 27-hydroxycholesterol (27OHC) from the circulation across the blood-brain barrier. Because there is a correlation between 27OHC and cholesterol in the circulation and lipoprotein-bound cholesterol does not pass the blood-brain barrier, we have suggested that 27OHC may mediate the effects of hypercholesterolemia on the brain. We previously demonstrated a modest accumulation of 27OHC in brains of patients with sporadic Alzheimer's disease (AD), consistent with a role of 27OHC as a primary pathogenetic factor. We show here that there is a 4-fold accumulation of 27OHC in different regions of the cortexes of patients carrying the Swedish amyloid precursor protein (APPswe) 670/671 mutation. The brain levels of sitosterol and campesterol were not signifi cantly different in the AD patients compared with the controls, suggesting that the blood-brain barrier was intact in the AD patients. We conclude that accumulation of 27OHC is likely to be secondary to neurodegeneration, possibly a result of reduced activity of CYP7B1, the neuronal enzyme responsible for metabolism of 27OHC. We discuss the possibility of a vicious circle in the brains of the patients with familial AD wh...