Interplay between NAD and acetyl‑CoA metabolism in ischemia-induced mitochondrial pathophysiology.

Brain injury caused by ischemic insult due to significant reduction or interruption in cerebral blood flow leads to disruption of practically all cellular metabolic pathways. This triggers a complex stress response followed by overstimulation of downstream enzymatic pathways due to massive activation of post-translational modifications (PTM). Mitochondria are one of the most sensitive organelle to ischemic conditions. They become dysfunctional due to extensive fragmentation, inhibition of acetyl‑CoA production, and increased activity of NAD consuming enzymes. These pathologic conditions ultimately lead to inhibition of oxidative phosphorylation and mitochondrial ATP production. Both acetyl‑CoA and NAD are essential intermediates in cellular bioenergetics metabolism and also serve as substrates for post-translational modifications such as acetylation and ADP‑ribosylation. In this review we discuss ischemia/reperfusion-induced changes in NAD and acetyl‑CoA metabolism, how these affect relevant PTMs, and therapeutic approaches that restore the physiological levels of these metabolites leading to promising neuroprotection.