Changes in cerebral metabolism during ketogenic diet in patients with primary brain tumors: 1 H-MRS study

J Neurooncol. 2017 Apr;132(2):267-275. doi: 10.1007/s11060-016-2364-x. Epub 2017 Jan 10.


Normal brain cells depend on glucose metabolism, yet they have the flexibility to switch to the usage of ketone bodies during caloric restriction. In contrast, tumor cells lack genomic and metabolic flexibility and are largely dependent on glucose. Ketogenic-diet (KD) was suggested as a therapeutic option for malignant brain cancer. This study aimed to detect metabolic brain changes in patients with malignant brain gliomas on KD using proton magnetic-resonance-spectroscopy (1H-MRS). Fifty MR scans were performed longitudinally in nine patients: four patients with recurrent glioblastoma (GB) treated with KD in addition to bevacizumab; one patient with gliomatosis-cerebri treated with KD only; and four patients with recurrent GB who did not receive KD. MR scans included conventional imaging and 1H-MRS acquired from normal appearing-white-matter (NAWM) and lesion. High adherence to KD was obtained only in two patients, based on high urine ketones; in these two patients ketone bodies, Acetone and Acetoacetate were detected in four MR spectra-three within the NAWM and one in the lesion area -4 and 25 months following initiation of the diet. No ketone-bodies were detected in the control group. In one patient with gliomatosis-cerebri, who adhered to the diet for 3 years and showed stable disease, an increase in glutamin + glutamate and reduction in N-Acetyl-Aspartate and myo-inositol were detected during KD. 1H-MRS was able to detect ketone-bodies in patients with brain tumors who adhered to KD. Yet it remains unclear whether accumulation of ketone bodies is due to increased brain uptake or decreased utilization of ketone bodies within the brain.

Keywords: 1H-MRS; Aceto-Acetate; Acetone; Glioma; Ketogenic diet; Ketone-bodies.

MeSH terms

  • Adult
  • Aged
  • Antineoplastic Agents, Immunological / therapeutic use
  • Aspartic Acid / analogs & derivatives
  • Aspartic Acid / metabolism
  • Bevacizumab / therapeutic use
  • Brain Neoplasms / diagnostic imaging
  • Brain Neoplasms / diet therapy*
  • Brain Neoplasms / drug therapy
  • Brain Neoplasms / pathology*
  • Cerebral Cortex / diagnostic imaging
  • Cerebral Cortex / metabolism*
  • Diet, Ketogenic / methods*
  • Female
  • Glucose / metabolism
  • Glutamic Acid / metabolism
  • Humans
  • Image Processing, Computer-Assisted
  • Longitudinal Studies
  • Magnetic Resonance Imaging
  • Magnetic Resonance Spectroscopy
  • Male
  • Middle Aged
  • Nutrition Assessment
  • Protons
  • Severity of Illness Index


  • Antineoplastic Agents, Immunological
  • Protons
  • Bevacizumab
  • Aspartic Acid
  • Glutamic Acid
  • N-acetylaspartate
  • Glucose