ABSTRACT. We examined the neuronal consequences of repeated brief episodes of in utero cerebral hypoxia-ischemia. Chronically instrumented fetal sheep were subjected to three 10-min episodes of reversible cerebral ischemia, repeated at either 1-h (n = 8) or 5-h ( n = 5) intervals.Four fetuses were subjected to a single 10-min of ischemia and 17 fetuses to a single 30-min of ischemia. Repeated insults altered the distribution of damage with relatively marked striatal injury compared with isolated episodes of ischemia ( p < 0.01). Frequent insults were associated with greater neuronal loss ( p < 0.01) and a failure to restore electrocorticographic activity and resolve cortical cytotoxic edema between insults. Intermittent cortical hyperexcitability developed after repeated insults irrespective of the interval between insults. These findings emphasize that repeated brief episodes of ischemia alter the distribution of damage and sensitize the fetal brain to neuronal injury, particularly if the episodes are frequent. Striatal damage may be a feature of multiple but not single insults. Epidemiologic studies have often failed to find a clear association between isolated episodes of fetal asphyxia and neurologic outcome in the newborn (1,2). This discrepancy may be due, in part, to multiple brief episodes of in utero asphyxia being unrecognized but more common than major and identifiable single events. However, few experimental studies have considered the neurologic consequences of multiple insults. Limited evidence from studies in the adult rat and gerbil suggests that brief episodes of ischemia repeated during the period of postischemic hypoperfusion may produce additive degrees of neuronal damage in the cortex, hippocampus, and caudate nucleus and vasogenic edema (3,4). We have previously shown that the parasagittal cortex and hippocampus are particularly vulnerable to both brief (lo-min) and prolonged (30-to 40-min) single episodes of cerebral ischemia or global asphyxia in the fetal sheep ( 5 , 6 ) . However, despite frequent clinical observations of striatal damage with perinatal encephalopathy (7), neither cerebral ischemia nor global asphyxia induced predominantly striatal patterns of injury.The objective of the study presented here was to determine whether multiple brief episodes of ischemia sensitize the fetal brain to injury or alter the pattern of damage compared with isolated insults and whether the length of the interval between insults is of importance. We have previously described an experimental preparation of transient cerebral ischemia in the chronically instrumented fetal sheep that induces encephalopathy similar to hypoxic-ischemic brain damage observed in some asphyxiated term infants (8). Therefore, we investigated the electrophysiologic and histologic consequences of isolated and brief episodes of reversible cerebral ischemia repeated at either 1 or 5 h. Fetal peripheral lactate and glucose levels were measured. We demonstrate that repeated insults, particularly if frequent, are associated with a...