Cerebral concentrations of phenylalanine (PHE) were measured by means of quantitative in vivo IH MR spectroscopy in 8 adult patients treated early for phenylketonuria type I. A 1.5-Tesla routine magnetic resonance scanner, localization sequence with short echo time (20 ms), and a fully automated data processing scheme were used. Baseline plasma PHE concentrations were 1.04 (0.70-1.39) mmol/L PHE with concurrent brain PHE concentrations of 0.27 (0.13-0.41) mmol/kg of wet weight resulting in a plasma/brain ratio of 4.12. Plasma and brain concentrations correlated significantly (Kendall T b = 0.91, P < 0.01). During an oral load with a single dose of 100 mg L-PHE per kg of body weight in four patients, plasma levels steeply increased. Concurrent brain PHE increase was less steep, was significantly delayed , and still continued up to 20 h postload. Despite the proven rise in plasma and brain concentr ations of PHE, neuropsychologic examinations revealed no impairment of attentional and fine motor abilities from preload up to 20 h postload. tPediatr Res 38: 657-663, 1995) Some 40 Y after its first description (1), the PHErestricted diet for pati ents with PKU is still an out standing example of the successful treatment of inborn errors of metabolism. Despite the overall favor able outcome compared with untreated patients, open questions rem ain and new problems arise. 1) The influence of the strictness of the diet on outcome has been demonstrated clearl y (2), but it is still uncl ear why some patients with norm al outcome see m to be "protected," in spite of adhering to no diet at all (3), where as other patients on diet show a decline in e.g . IQ. 2) A rever sible impairment of cognitive function and EEG Received February 27, 1995; accepted May 11, 1995 activit y has been dem onstrated during PHE challenges (4). The decre ase in performance was , however, onl y weakl y relat ed to the total increase of plasma PHE , dem onstrating an intcrindividuall y variable sensitivity to PHE. 3) Neurologic symptoms have been observed in adult pati ent s off diet (5), which were partly reversible after reinstitution of a PHE-restr icted diet. In thes e, but also in neur ologicall y unaffec ted PKU patients, white matter chan ges have been obs erved in MRI (6). Lowering plasma PHE levels improved changes in some case s.In all areas mentioned, PHE and its impact on brain morphology and function seems to be a key explanatory factor. Access to a comp artment "closer to the brain" is possible by lumbar puncture, although in otherwise healthy patients it is ethically questionable. Using an animal model of hyperphenylalanin emia, Avison et at. (7) were able to show that PHE was detectable by 1H MRS in the brains of rabbits in vivo. Post-