Therapeutic recommendations for management of severe hyponatremia: current concepts on pathogenesis and prevention of neurologic complications

Patients with hyponatremia are exposed to major neurological complications. On the one hand hyponatremia itself produces brain edema, increased intracranial pressure which potentially leads to subsequent neuropathological sequelae or death. On the other hand excessive correction could be followed by development of brain demyelinating lesions (central pontine or extrapontine myelinolysis) with major disability or fatal outcome. Understanding of brain adaptative mechanisms to changes in osmolality largely contributes to explain these neurological events. When serum sodium decreases, the brain prevents swelling by extruding electrolytes and organic osmolytes, a process almost fully achieved after 48 h. Conversely, during subsequent increase in serum sodium, reestablishment of intracerebral osmolytes occurs but their reuptake is more delayed (+/- 5 days). In both circumstances, these mechanisms can be overwhelmed, leading to brain damage. Acute hyponatremia (< 48 h) is generally hospital-acquired, mainly in the postoperative state and/or after excessive fluid administration. After abrupt fall in serum sodium, seizure, respiratory arrest and coma may develop and these manifestations are sometimes explosive in nature. Recognition of even minor symptoms is crucial and implies prompt correction. There is generally no risk of brain myelinolysis in acute hyponatremia. Some factors are suspected to aggravate the prognosis of hyponatremic encephalopathy, including female gender (menstruant women), hypoxia and young age. Chronic hyponatremia (> 48 h) usually develops outside the hospital and is generally better tolerated. The risks of brain myelinolysis can be largely reduced by limiting the correction level to < or = 15 mEq/1/24 h. However, if necessary, the initial rate of correction can be rapid provided that the final correction remains < 15 mEq/1/24 h. However, when other recognized risk factors for myelinolysis (hypokalemia, liver disease, poor nutritional state, burns) are present, correction should not exceed 10 mEq/1/24 h. Demyelinization is also observed in hypernatremia but it follows greater (50%) increase in serum sodium than from hyponatremic baseline. For symptomatic hyponatremia, rapid correction is usually obtained by hypertonic saline (3%) infusion. Another option consists in administration of intravenous or oral urea. Urea allows a rapid reduction of brain edema and intracranial pressure which is followed by subsequent correction of hyponatremia. Experimental data also suggest that treatment of hyponatremia with urea is associated with a lower incidence of myelinolysis. In hyponatremic patients without symptoms, there is no need for rapid correction and the treatment should be more conservative. Close monitoring of the serum sodium is indicated initially and if necessary, correction must be stopped and diuresis interrupted with dDAVP. Given recent experimental data, in patients overly corrected (delta SNa > 15 mEq/1/24 h), the risk of myelinolysis could be greatly reduced by rapidly decreasing the serum sodium through hypotonic fluids administration and dDAVP.

HMPAO SPECT to assess neurologic deficits during balloon test occlusion

The purpose of this study was to determine if one could objectively and preoperatively predict the safety of permanent occlusion of an internal carotid artery with 99mTc-HMPAO brain SPECT.

METHODS

Twenty-four patients underwent balloon test occlusion of the internal carotid arteries because of neck and skull base tumors. We assessed the uptake of both middle cerebral artery territories before and during balloon test occlusion with 99mTc-HMPAO brain SPECT using the semiquantitative analysis. The results were compared with other factors, including neurologic examination, arterial stump pressure and electroencephalogram.

RESULTS

Nineteen patients experienced no neurological deterioration or any problem during balloon test occlusion. The comparative uptake of their middle cerebral artery territories was 95%-101% of the pre-balloon test occlusion state. The remaining five patients showed severe neurologic symptoms, such as transient hemiplegia and unconsciousness. The comparative uptake of their middle cerebral artery territories was 77%-85% of the pre-balloon test occlusion state and was well matched with other factors.

CONCLUSION

Technetium-99m-HMPAO brain SPECT before and during balloon test occlusion seems to be a simple and objective method for predicting permanent neurologic deficits when the comparative uptake of middle cerebral artery territories during balloon test occlusion is less than 85% of that before balloon test occlusion.

Risk factors for intellectual and educational sequelae of cranial irradiation in childhood acute lymphoblastic leukaemia

Long-term cognitive and educational sequelae have been inconsistently reported in children who received cranial irradiation (CRT) to prevent central nervous system (CNS) disease in acute lymphoblastic leukaemia (ALL). This study investigates a large and representative sample of survivors of ALL and compares them with non-irradiated survivors of cancer and healthy control children to determine the effect of CRT on cognitive and educational ability. Three groups of children were studied: Group 1 (n=100) survivors of ALL treated with chemotherapy and CRT, group 2 (n=50) children with a variety of malignancies treated with chemotherapy alone, group 3(n=100) healthy children. Cognitive and educational abilities of these groups were evaluated using standardised psychometric techniques. Significant differences in cognitive and educational abilities were found between the children in group 1 (chemotherapy + CRT) and the two control groups, with the children receiving CRT performing less well in a range of tests. Greatest differences were detected for tasks dependent on language function including verbal IQ, reading and spelling. Within group 1 a younger age at treatment (less than 5 years) and a higher dose of CRT (24 Gy vs 18 Gy) were predictive of poor long-term outcome for cognitive and education ability. In contrast, children who received chemotherapy alone, with or without intrathecal methotrexate, performed similarly to healthy controls. No gender differences were detected for these measures.

Protective effects of Ca2+ channel blockers against methyl mercury toxicity

The protective effects of Ca2+ channel blockers against the toxicity of methyl mercury were examined by both in vivo and in vitro experiments. In the in vivo study we first examined the effects of the Ca2+ channel blockers (20 mg/kg/day), flunarizine, nifedipine, nicardipine, and verapamil against the toxic level of methyl mercury treatment (5 mg/kg/day of methyl mercuric chloride for 12 consecutive days). However, there was a difference in potency of the effects among the reagents. All the Ca2+ channel blockers prevented a decrease in body weight and/or the appearance of the symptoms of neurological disorders in the rats treated with methyl mercury. In the next experiment, we examined flunarizine at different levels of supplementation (1, 25 and 50 mg/kg/day). Flunarizine in a dose-dependent manner prevented a decrease in body weight, appearance of the symptoms of neurological disorder and mortality in the rats treated with methyl mercury. Flunarizine treatment (25 mg/kg/day) for the first 5 days did not affect mercury distribution among the tissues, suggesting that the mechanism of protection against methyl mercury-induced toxicity may be attributed to its own pharmacological effect. In the in vitro study we examined the effect of flunarizine (0, 0.5, 5 and 50 microM) using primary cultures of cerebellar granular cells in 96-well culture plates. Viable cell numbers were estimated 1 and 3 days after treatment with methyl mercury. The estimated 50% lethal concentration (LC50) of methyl mercury was higher in plates treated with 5 and 50 microM of flunarizine both on days 1 and 3, indicating that flunarizine protected the primary cultured cerebellar granular cells against the toxicity of methyl mercury. As such, Ca2+ channel blockers protected against the toxicity of methyl mercury both in vivo and in vitro, suggesting that Ca2+ plays an important role in the mechanisms of methyl mercury toxicity.

Baylisascaris procyonis larva migrans in a puppy: a case report and update for the veterinarian

Baylisascaris larva migrans (LM) has been recognized as a cause of central nervous system (CNS) disease in puppies. A presumptive antemortem diagnosis is based on a history of raccoon exposure, clinical signs, cerebrospinal fluid eosinophilic pleocytosis, and peripheral blood eosinophilia. Early diagnosis is critical for treatment or prevention of disease in other dogs, animals, or humans exposed to the suspected contaminated area. In the present case, an antemortem diagnosis was not made, emphasizing the importance of postmortem examination in cases of CNS disease in puppies.

Caffeine attenuates CNS oxygen toxicity in rats

We tested the effect of caffeine, on hyperoxia-induced seizures. Thirty-seven rats with chronic cortical electrodes were injected i.p. with caffeine (1.25, 2.5, and 10 mg/kg) or vehicle before exposure to 0.5 MPa oxygen and 17 rats to oxygen with 5% CO2 at 0.5 MPa. EEG monitoring and spectral analysis of EEG activity were carried out. Caffeine significantly prolonged the latent period to the onset of seizures (P < 0.05 in ANOVA), in a dose-related manner. Our results suggest that caffeine may be used in low doses for protection against hyperoxia-induced seizures.

Intraoperative echocardiographic study of air embolism during cardiac operations

BACKGROUND

Central nervous system damage remains a feared complication after heart operations. Air embolism (AE) is one of several possible causes of central nervous system damage. In previous studies, intraoperative transesophageal echocardiography (ITEE) has been used to detect AE, but identification of the periods of risk and the origin of AE is lacking.

METHODS

Two groups of patients undergoing elective heart operations were studied with ITEE. Group I consisted of 15 patients undergoing true "open heart" operations, either aortic or mitral valve. Group II consisted of 15 patients undergoing coronary artery bypass grafting.

RESULTS

In group I (valve operation), ITEE detected AE in all patients, particularly in the period between the release of the aortic cross-clamp and the termination of cardiopulmonary bypass. Furthermore, 12 of the 15 patients had new episodes of AE up to 28 minutes after termination of cardiopulmonary bypass. In the majority of cases, ITEE clearly demonstrated that the air originated in the lung veins and was not air retained in the heart. In group II (coronary artery bypass grafting) episodes of AE were only seen in the period between cross-clamp removal and the termination of cardiopulmonary bypass, and only in half of the patients.

CONCLUSIONS

Careful standard cardiac deairing did not prevent AE caused by the delayed release of air trapped in the lung vessels. Routine use of ITEE is recommended to assess the thoroughness of deairing procedures. This will help eliminate AE or at least lead to an increased awareness of the problem of retained air. Minimizing AE during open heart operations should contribute to a reduction in central nervous system damage and improvement of intellectual function after heart operations.

Protective effect of riluzole on excitatory amino acid-mediated neurotoxicity in motoneuron-enriched cultures

Excitatory amino acid-mediated neurotoxicity was investigated in motoneuron-enriched cultures from fetal rats at 12-14 days of gestation. The cultures were mainly composed of differentiated motoneurons identified by choline acetyl transferase and calcitonin gene-related peptide (CGRP) immunoreactivity. Addition of glutamate (600 microM) to the conditioned medium induced no acute neuronal swelling. However, it was followed by a widespread neuronal degeneration over the next 24 h, accounting for 77% of the total cell number. Glutamate toxicity was dose dependent, with an EC50 around 300 microM. Treatment for 24 h with the agonists, N-methyl-D-aspartate (NMDA, 100 microM), kainate (500 microM) or RS-alpha-amino-3-hydroxy-5-methyl-4-isoxalopropionate (AMPA, 10 microM), also induced a significant cell loss. Riluzole (2 amino 6-trifluoromethoxybenzothiazole), a compound known to interfere with glutamatergic transmission pre- and postsynaptically, significantly reduced glutamate and NMDA neurotoxicity in a dose-dependent manner. These results suggest that a prolonged activation of one or more subtypes of ionotropic excitatory amino acid receptors can lead to motoneuron degeneration in vitro, and provide direct experimental evidence supporting the neuroprotective effect of riluzole in cultured motoneurons.

Hypoxic cardiopulmonary-cerebral resuscitation fails to improve neurological outcome following cardiac arrest in dogs

Hyperoxic cardiopulmonary resuscitation (CPR) is associated with an increase in neurologic dysfunction upon successful resuscitation with much of the damage attributable to an increase in reperfusion oxidant injury. We hypothesized that by contrast, hypoxic ventilation during resuscitation would improve neurologic outcome by reducing available substrate necessary for oxidant injury. Specifically, this study investigated the effects of 2 levels of hypoxic ventilation during resuscitation: F1O2 = 0.085, PaO2 = 26.6 +/- 3.4 mmHg, (HY8), and F1O2 = 0.12, PaO2 = 33.0 +/- 4.2 mmHg, (HY12), and normoxic resuscitation: F1O2 = 0.21, PaO2 = 60.6 +/- 17.0 mmHg, (N) on survival and neurological outcome following 9 min of normothermic cardiac arrest. Concentrations of malonaldehyde (MDA) and 4-hydroxynonenal (4-OH) in plasma and concentrations of glutathione (GSH) in erythrocyte lysates were measured to quantify possible radical damage. Physiological variables including arterial blood gases were followed for 24 h after resuscitation. Neurologic outcome was assessed using a standardized scoring system. Hypoxically (HY8) resuscitated dogs tended to have a greater neurologic deficit than normoxically resuscitated dogs and had reduced overall survival (16.9 +/- 8.9 h) compared to N dogs (24.0 +/- 0.0 h). Overall survival time correlated negatively (-0.693) and significantly (P = 0.0018) with plasma glucose concentration. Arterial plasma glucose concentrations were higher in the HY8 group compared to the N group immediately (HY8, 312 +/- 86 mg/dL; N, 196 +/- 82 mg/dL; P = 0.17) and 30 min (HY8, 331 +/- 109 mg/dL; N, 187 +/- 74 mg/dL; P = 0.077) following resuscitation. No statistically discernible differences in markers of oxidant injury were apparent among the 3 groups, but pooled data increased significantly with time for MDA and 4-OH. Pooled data for GSH showed a significant drop at 1 h following resuscitation and returned to normal by 6 h. Data from these markers suggested attendant oxidant injury in all groups. Thus, hypoxic ventilation at 2 depths of hypoxia during resuscitation failed to improve neurologic outcome beyond that achieved by ventilation with air, suggesting that normoxia rather than hyperoxia or hypoxia is the ideal target for arterial oxygenation during resuscitation.

Protection against CNS ischemia by temporary interruption of function-related processes of neurons

Previous studies have shown that most of the energy consumption of CNS tissue is used for processes that subserve signaling functions of the cells. Since these function-related processes are probably not essential to cell viability, blocking them reversibly with a combination of pharmacologic agents should protect cells from a reduction in energy metabolism. Preliminary experiments to test this hypothesis were performed on isolated rabbit retinas. They were maintained in a newly devised chamber that permitted continuous monitoring of electrophysiological function for > or = 8 h. Ischemia was simulated by a 6-fold reduction in both O2 and glucose. This caused a rapid (t1/2 75 s) and complete loss of the light-evoked response in the optic nerve. Untreated retinas showed full recovery after 1/2 h of deprivation, but only 50% recovery after 1 h and little or no recovery after 2 or 3 h. Retinas exposed during 3 h of deprivation to a combination of six agents that abolished electrophysiologic function and reduced glucose utilization [tetrodotoxin (TTX), 2-amino-4-phosphonobutyric acid (APB), 2-amino-5-phosphonovaleric acid (APV), amiloride, Mg2+, and Li+] showed full recovery. We conclude that reducing energy requirements by blocking functional processes can prevent ischemic damage.

Prospects for the use of antioxidant therapies

Free radical oxidative stress has been implicated in the pathogenesis of a variety of human diseases. Natural antioxidant defences have been found to be defective in many of the same diseases. This has led to suggestions that oxidative damage and therefore disease progression may be retarded by supplementing natural antioxidant defences. Potential antioxidant therapy includes natural antioxidant enzymes and vitamins or synthetic agents with antioxidant activity. Diseases where antioxidant therapy may be beneficial include diabetes mellitus, reperfusion injury, inflammatory diseases and the prevention of chronic processes such as atherosclerosis and carcinogenesis. Further well controlled prospective clinical trials of antioxidants are required to establish the efficacy and tolerability of antioxidant therapy in the treatment of human diseases.

Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity

Hypothermic circulatory arrest has become an accepted technique for a variety of cardiac and complex aortic operations. However, prolonged periods (> 45 min) of hypothermic circulatory arrest in older patients is associated with marginal cerebral protection and an increased incidence of adverse neurologic events. In an effort to minimize such morbidity, we used a technique of retrograde cerebral perfusion with continuous monitoring of cerebral hemoglobin oxygen saturation during hypothermic circulatory arrest in 35 patients who underwent thoracic aortic operations or resection of intracardiac tumor. There were 27 men and 8 women (mean age 60 years, range 21 to 83 years). Sixteen patients had acute dissection, 6 had contained rupture of a thoracic aortic aneurysm, 10 had either a chronic dissection or aneurysm, and 3 had hypernephromas extending into the heart. Six patients underwent root replacement by means of an open technique for their distal anastomosis, 7 underwent root and partial arch replacement, 12 had root and total arch replacement, 7 had total arch replacement, and 3 had resection of tumor in the heart and retrohepatic vena cava. Seven patients had simultaneous coronary artery bypass grafting, 3 had replacement of one of the arch vessels, and 2 patients had a cesarean section. Sixteen cases were emergency, 6 urgent, and 13 elective. Nine (26%) were reoperations. Thirty-four patients underwent the procedure via a median sternotomy and one patient through a posterolateral thoracotomy. The mean retrograde cerebral perfusion time was 63 minutes (range 35 to 128 minutes), with 30 (86%) patients having more than 45 minutes, 12 (34%) having more than 65 minutes, and 4 (11%) having more than 90 minutes. There was 1 operative death caused by a preoperative myocardial infarction from an aortic dissection, and there were 2 late deaths (multiple organ failure and ruptured total aortic aneurysm). One patient had a stroke with a residual right hemiplegia and a pronounced aphasia. There were no other significant neurologic events or reoperations for bleeding. The average length of stay for patients having elective operations was 11 days and for those having emergency operations, 27 days. At a mean follow-up of 6 months all surviving patients (91%) are well. Hypothermic circulatory arrest is a relatively simple technique that provides a bloodless field and good visualization without the need for aortic crossclamps. Moreover, retrograde cerebral perfusion with continuous monitoring of cerebral oxygen saturation extends the "safe" time for hypothermic circulatory arrest, allowing ample opportunity to perform complicated cardiac and aortic operations with reduced risk of adverse neurologic events.

Prevention of retrovirus-induced neurological disease by infection with a nonneuropathogenic retrovirus

Perinatal infection of susceptible mice with the neurotropic retrovirus CasBrE leads to a noninflammatory spongiform degeneration of the central nervous system with a long incubation period of up to 1 year. Virus replication in infected animals can be suppressed by administration of antiviral antibodies, cytotoxic T cells, or by AZT treatment, which results in partial to complete protection from neurological disease. A highly neuropathogenic chimeric retrovirus, FrCasE, which contains the envelope gene of CasBrE, induces rapid neurodegeneration within only 16 days. Here we report that this fatal disease could be prevented if a nonneuropathogenic Friend murine leukemia virus was administered to mice prior to their infection with FrCasE. This double inoculation led to a substantial reduction of the replication level of FrCasE in spleen and CNS. Only live but not heat-inactivated nonneuropathogenic virus was able to protect from FrCasE-induced neurological disease. The extent of protection was influenced by the viral envelope gene and the kinetics of replication of the nonneuropathogenic virus. These observations in addition to the rapidity of the effect make it likely that competition for replication sites through the mechanism of viral interference is responsible for the protection. Resistance was demonstrable in vivo even when the "protecting" and "challenge" virus belonged to different in vitro interference groups. However, the protection was considerably weaker than that seen between viruses belonging to the same interference group.

Low numbers of CSF blasts at diagnosis do not predict for the development of CNS leukemia in children with intermediate-risk acute lymphoblastic leukemia: a Childrens Cancer Group report

PURPOSE

This study was designed to evaluate the effect on CNS relapse (CNSR) and overall relapse rates of blast cells in the CSF containing < or = 5 cells/microL at the time of diagnosis of intermediate-risk acute lymphoblastic leukemia (ALL) in children entered onto a large randomized multicenter prospective therapeutic trial (Childrens Cancer Group [CCG]-105).

PATIENTS AND METHODS

We studied outcome in terms of CNSR and event-free survival (EFS) in 1,544 patients who successfully completed remission-induction therapy and had been randomized to one of four systemic chemotherapy regimens and to one of two CNS prophylaxis regimens. We compared outcome between 1,450 patients who had varying degrees of pleocytosis but no blasts in the CSF at diagnosis (blast-negative group) with 94 who had blasts detected in the CSF after cytocentrifugation but had a total CSF WBC count of < or = 5/microL (blast-positive group).

RESULTS

No statistically significant differences in overall CNSR or EFS rates were observed between the two groups and no differences were found when analyzed according to age or WBC count at diagnosis, sex, or type of CNS prophylaxis (intrathecal [IT] methotrexate [MTX] alone v IT MTX plus 18 Gy cranial irradiation [CXRT]).

CONCLUSION

In intermediate-risk ALL, there was no significant difference in CNSR and systemic relapse rates after standard presymptomatic CNS therapy between patients with a CSF WBC count < or = 5/microL and those without identifiable blasts in the CSF. These findings suggest that certain approaches to therapy, such as that used in this study, may eliminate the need for any additional special treatment directed at this subset of patients with CSF blasts.

Calpain inhibition: an overview of its therapeutic potential

Increasing evidence now suggests that excessive activation of the Ca(2+)-dependent protease calpain could play a key or contributory role in the pathology of a variety of disorders, including cerebral ischaemia, cataract, myocardial ischaemia, muscular dystrophy and platelet aggregation. In this review, Kevin Wang and Po-Wai Yuen discuss the evidence linking these disorders to calpain overactivation. At present, it is difficult to confirm the exact role of calpain in these disorders because of the lack of potent, selective and cell-permeable calpain inhibitors. However, given the multiple therapeutic indications for calpain, it appears that achievement of selective calpain inhibition is an important pharmacological goal.

5-Ethynyluracil (776C85): protection from 5-fluorouracil-induced neurotoxicity in dogs

5-Ethynyluracil (776C85) is a potent mechanism-based inactivator of dihydropyrimidine dehydrogenase (DPD), the enzyme that catalyzes the rapid catabolism of 5-fluorouracil (5-FU). Because catabolism is the major route for 5-FU clearance, we studied the effect of 5-ethynyluracil on the pharmacokinetics and toxicity of continuous i.v. 5-FU infusion in the dog. 5-FU at 40 mg/kg/24 hr resulted in a steady-state plasma 5-FU concentration of 1.3 microM and was fatal with dogs dying from apparent neurotoxicity. 5-Ethynyluracil lowered the total clearance of 5-FU from 9.9 to 0.2 L/hr/kg and enabled 1.6 mg/kg/24 hr 5-FU to achieve a steady-state plasma 5-FU concentration of 2.4 microM with no apparent toxicity. 5-FU at 4 mg/kg/24 hr achieved a steady-state plasma 5-FU concentration of 5.3 microM and produced only mild gastrointestinal disturbances in 5-ethynyluracil-treated dogs. Thus, a catabolite of 5-FU appears to be responsible for the 5-FU-induced neurotoxicity in dogs.

Effect of antioxidants on ammonia induced CNS-renal pathobiology in sheep

The effect of antioxidants on ammonia induced CNS and renal pathobiology in 10 sheep infested by L. Cuprina larvae was investigated. The condition produces severe dermatitis, proliferation of macrophages and hyperammonaemia, and free radicals may therefore be involved in the pathogenesis. Five of the sheep (treated group) were given daily intramuscular (im) injections of 2 g sodium ascorbate, 5.9 g dl-alpha tocopherol (11 days) and 3 g desferrioxamine mesylate (6 days) with 70 mg oral butylated-hydroxyanisole (11 days). The treatment prevented rises in jugular ammonia, creatinine, urea, sodium and pH, and decreases in water intake, urine output and glucose. The findings showed that antioxidants prevented ammonia induced CNS and renal pathobiology and suggest that free radicals contribute to the pathogenesis of the condition.

Glutamate excitotoxicity: a mechanism of neurologic injury associated with hypothermic circulatory arrest

Glutamate, the major central nervous system neurotransmitter, may have potent neurotoxic activity under conditions of metabolic stress. By receptor autoradiography, we have demonstrated that brain regions most vulnerable to injury during prolonged hypothermic circulatory arrest have the highest density of glutamate receptors. To test the hypothesis that such injury could be mediated by glutamate excitotoxicity, we used dizocilpine (MK-801), a selective N-methyl-D-aspartate-glutamate receptor antagonist in a canine survival model of hypothermic circulatory arrest. Eighteen male dogs (20 to 25 kg) were supported by closed-chest cardiopulmonary bypass, subjected to 2 hours of hypothermic circulatory arrest at 18 degrees C, and rewarmed on cardiopulmonary bypass. All were mechanically ventilated and monitored for 20 hours before extubation and survived for 3 days. Group A dogs (n = 9) received a prearrest intravenous bolus of dizocilpine (0.75 mg/kg) followed by continuous infusion (75 micrograms/kg per hour), resulting in electroencephalographic silence. Dizocilpine was weaned before extubation. Group B dogs received vehicle only. According to a species-specific behavior scale that yielded a neurologic deficit score ranging from 0 (normal) to 500 (brain dead), all animals were neurologically assessed every 12 hours. After the dogs were killed at 72 hours, brains were examined by receptor autoradiography and histologically for patterns of selective neuronal necrosis; they were scored blindly from 0 (normal) to 100 (severe injury). Group A dogs had better neurologic function than group B (neurologic deficit score 21 +/- 15 versus 192 +/- 40, p < 0.001) and had less neuronal injury (7.3 +/- 3 versus 48.3 +/- 9, p < 0.0001). Densitometric receptor autoradiography revealed preservation of neuronal N-methyl-D-aspartate-glutamate receptor expression in group A only. These results represent the first direct evidence of a role for glutamate excitotoxicity in the development of hypothermic circulatory arrest-induced brain injury and suggest that selective glutamate receptor antagonists may have a neuroprotective capacity in prolonged periods of hypothermic circulatory arrest.