β-Hydroxybutyrate Maintains Energetically Demanding Neural Functions During Exogenous Glucose Deprivation

Ketone bodies are a major source of cerebral energy during fasting and the ketogenic diet, but whether they can sustain brain tissue metabolism when glucose is absent remains uncertain. This question is difficult to resolve in vivo because circulating glucose is maintained, even during starvation, through endogenous production. We therefore used an ex vivo brain preparation to examine the metabolic capacity of tissue following incubation with β-hydroxybutyrate (BHB) as the only exogenous fuel, isolating brain tissue from its primary endogenous glucose sources. Mitochondrial respiration was monitored following 4-hour incubation in glucose-free, BHB-rich artificial cerebrospinal fluid, and tissue resilience was tested by inducing spreading depolarization, a severe energetic challenge that requires rapid restoration of ionic and metabolic homeostasis. Following acute reliance on exogenous BHB, in addition to endogenous energy reserves, mitochondrial electron transfer system function persisted, with lower O2 flux than following incubation with exogenous glucose. BHB-supported tissue maintained sufficient energetic capacity to generate and recover from repeated spreading depolarizations. In contrast, tissue relying solely on endogenous energy reserves failed to undergo repeated spreading depolarizations, suggesting that exogenous BHB provided the needed short-term energetic support beyond that available from endogenous substrates in the complete absence of exogenous glucose. The results broaden our understanding of cerebral fuel flexibility and provide evidence that BHB can support highly energetic neural function in the absence of exogenous glucose. Cerebral fuel flexibility: glucose and ketones. Mitochondrial respiration continued with reduced O2 flux following β-hydroxybutyrate (BHB) incubation in the absence of exogenous glucose. BHB-supported brain slices generated and recovered from repeated spreading depolarizations (SD), whereas slices relying on endogenous energy reserves alone did not sustain repeated SDs. Together, these findings demonstrate that ketone-supported brain slices can sustain energetically demanding neural function beyond that supported by endogenous fuel reserves alone. ADP, adenosine diphosphate; ATP, adenosine triphosphate; Cyt c, cytochrome c; TCA, tricarboxylic acid. Created in BioRender. Parrish, R. (2026) https://BioRender.com/egdxr0j