The enzymatic conversion of CNS cholesterol to 24S-hydroxycholesterol, which readily crosses the blood-brain barrier, is the major pathway for brain cholesterol elimination and brain cholesterol homeostasis maintenance. The enzyme mediating this conversion has been characterized at the molecular level (CYP46) and is mainly located in neurons. Like other oxysterols, 24S-hydroxycholesterol is efficiently converted into normal bile acids or excreted in bile in its sulfated and glucuronidated form. Levels of 24S-hydroxycholesterol in the circulation decrease with age in infants and children. In adults, however, the levels appear to be stable. There is accumulating evidence pointing toward a potentially important link between cholesterol, beta-amyloid, and Alzheimer's disease. Concentrations of 24S-hydroxycholesterol in plasma and cerebrospinal fluid (CSF) are significantly higher in Alzheimer's disease and vascular demented patients at early stages of the disease compared to healthy subjects. Variations in genetic background, time of disease onset, and severity of dementia are potential sources of variance. Inhibitors of cholesterol biosynthesis, also termed statins, seem to have a reductive influence on the generation of the amyloid precursor protein, the neuronal secretion of beta-amyloid, and on de novo cholesterol synthesis. Recent epidemiological studies indicate that the prevalence of diagnosed AD and vascular dementia is reduced among people taking statins for a longer period of time. High-dose simvastatin treatment (80 mg/day) in patients with hypercholesterolemia leads to a significant decrease in brain-specific serum 24S-hydroxycholesterol concentrations and indicates a diminished cholesterol metabolism in the brain. CSF levels of cholesterol and lathosterol, a cholesterol precursor considered to be an indicator for cholesterol neogenesis, were significantly decreased in statin-treated subjects compared to non-treated normo- and hypercholesterolemic subjects. Also, CSF concentrations of 24S-hydroxycholesterol were significantly lower in statin-treated patients compared to normocholesterolemic subjects. Treatment with high-dose simvastatin in normocholesterolemic Alzheimer patients for 26 weeks at early stages of the disease results in a significant decrease in Abeta-levels in cerebrospinal fluid. This decrease correlates with the reduction of 24S-hydroxycholesterol.