This review proposes two stages of alcohol-related white matter degeneration with different mechanisms and treatment targets.
Evidence
The evidence is a mechanistic review of alcohol-related cerebral white matter damage, spanning early stress, vascular, inflammatory, and oxidative changes and later impaired insulin/IGF Akt-mTOR signaling.
Caveat
The staged treatment model is presented as a hypothesis rather than tested clinical evidence.
Simplified
Long-term effects of (ARBD) include neurocognitive and neurobehavioral dysfunctions with neurodegeneration. White matter (WM) is notably targeted across the lifespan yet relatively little is known about the stages, mechanisms, and consequences of myelin and axonal loss. In alcohol-related liver disease, early pathology is reversible, but with chronic heavy alcohol exposures, disease progresses with degeneration, and ultimately organ failure. Similarly, WM ARBD also develops in two broad stages. The early stages of WM ARBD are likely mediated by vascular dysfunction with tissue swelling, oligodendrocyte dysfunction, myelin loss, neuroinflammation, and oxidative stress. The chronic progressive stage is linked to metabolic dysfunction related to impairments in insulin and insulin-like growth factor signaling through Akt-mechanistic target of rapamycin (mTOR) pathways that mediate oligodendrocyte survival and function, myelin homeostasis, and blood-brain-barrier (BBB) integrity. We hypothesize that early-stage WM ARBD may be largely reversible by abstinence and anti-oxidant/anti-inflammatory measures, whereas late-stage ARBD requires strategies to restore WM/oligodendrocyte metabolic function via insulin sensitizer, antioxidant, anti-inflammatory, and myelin homeostasis/normalization support. Multi-pronged, overlapping but distinct therapeutic strategies are needed to reduce the impact and long-term health consequences of chronic progressive WM ARBD.
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