Neurotransmitters and pathophysiology of stroke: evidence for the release of glutamate and other transmitters/mediators in animals and humans.

There is convincing evidence from animal models of stroke that ischemia leads to an increase in the extracellular concentrations of excitatory amino acids (EAAs), especially glutamate. This accumulation of glutamate, which can reach up to 80 times normal at the centre of an ischemic lesion, is believed to be an important factor for the premature death of neurons that would otherwise survive the ischemic conditions and recover when flow is restored. In the technique of microdialysis, a small probe is inserted into the brain tissue. Fluid passing through the probe is separated from the brain parenchyma by a semipermeable membrane, through which substances released into the brain can diffuse. Analysis of the dialysate allows the nature and time course of release of substances, such as glutamate, to be determined. This technique has been used in patients undergoing resection of cerebral tumors, surgery for epilepsy, head trauma, subarachnoid hemorrhage, and cerebral infarction. Clamping or ligating the blood supply to the lobe about to be excised leads to a rapid accumulation in the dialysate of, among other substances, glutamate. Similar findings have been obtained during lobar resection for the treatment of severe epilepsy. Accumulations of glutamate to approximately 100 times the basal concentration have been found. There are also a few reports of microdialysis being performed in patients undergoing lobectomy after severe strokes or extracranial-intracranial bypass surgery. Again, high concentrations of glutamate have been reported. Another approach is to examine the blood and cerebrospinal fluid (CSF) for traces of EAAs. High concentrations of glutamate have been found in the blood and CSF within 24 hours of the onset of stroke. In animal models, plasma concentrations of glutamate begin to rise some 4 to 6 hours after middle cerebral artery (MCA) occlusions, reaching a peak at about 8 to 24 hours. Similarly, when glutamate is injected into the CSF of rats, there is a lag of approximately 4 hours before the concentration of glutamate in the blood rises. Therefore, it may be possible to detect the ongoing release of glutamate into the brain as a result of cerebral ischemia, which may aid in the selection of the most appropriate treatment. The results of microdialysis and plasma EAA analyses suggest that excitotoxic damage can occur over many hours. This implies that effective neuroprotectant strategies could provide clinical benefits over similarly prolonged periods.