Acute liver failure (ALF) results in alterations of energy metabolites and of glucose-derived amino acid neurotransmitters in brain. However, the dynamics of changes in glucose metabolism remain unclear. The present study was undertaken using 1 H and 13 C nuclear magnetic resonance (NMR) spectroscopy to determine the rates of incorporation of glucose into amino acids and lactate via cell-specific pathways in relation to the severity of encephalopathy and brain edema in rats with ALF because of hepatic devascularization. Early (precoma) stages of encephalopathy were accompanied by significant 2-to 4.5-fold (P < .001) increases of total brain glutamine and lactate concentrations. More severe (coma) stages of encephalopathy and brain edema led to a further significant increase in brain lactate but no such increase in glutamine. Furthermore, 13 C isotopomer analysis showed a selective increase of de novo synthesis of lactate from [1-13 C]glucose resulting in 2.5-fold increased fractional 13 C enrichments in lactate at coma stages. [2-13 C]glutamine, synthesized through the astrocytic enzyme pyruvate carboxylase, increased 10-fold at precoma stages but showed no further increase at coma stages of encephalopathy. 13 C-label incorporation into [4-13 C]glutamate, synthesized mainly through neuronal pyruvate dehydrogenase, was selectively reduced at coma stages, whereas brain GABA synthesis was unchanged at all time points. In conclusion, increased brain lactate synthesis and impaired glucose oxidative pathways rather than intracellular glutamine accumulation are the major cause of brain edema in ALF. Future NMR spectroscopic studies using stable isotopes and real-time measurements of metabolic rates could be valuable in the elucidation of the cerebral metabolic consequences of ALF in humans. (HEPATOLOGY 2003;37:420-428.) H epatic encephalopathy and brain edema are serious central nervous system complications of acute liver failure (ALF), which are accompanied by significant alterations of brain metabolites. For example, biochemical studies in brain tissue from animals with ALF resulting from hepatectomy, 1 hepatic devascularization, 2-4 or toxic liver injury 5 as well as autopsied brain tissue from patients with ALF 6 reveal significant increases in concentrations of glutamine and a concomitant reduction of glutamate. Several of these studies also show that brain lactate concentrations are elevated as a function of the deterioration of central nervous system function in ALF, a finding that has been attributed to decreased pyruvate oxidation because of ammonia exposure. 7 Although these biochemical studies provide important hints on metabolic derangements in ALF, they do not permit the elucidation of rates of synthesis/degradation of these metabolites, nor do they provide information on the cellular localization of the altered metabolism. The use of nuclear magnetic resonance (NMR) spectroscopy and stable isotope precursors provides an effective approach to the study of metabolic turnover in the brain. In particular, ...