Abstract It is widely believed that the proper activation of N-methyl-D-aspartate (NMDA) receptors (NMDARs) promotes neuronal survival, whereas an excessive activation of NMDARs leads to neuronal damage. NMDARs are found at both synaptic and extrasynaptic sites. One current prevailing theory proposes the dichotomy of NMDAR activity. The role of the two population receptors is mutual antagonism. The activation of synaptic NMDARs, such as synaptic activity at physiological levels, promotes neuronal survival. However, the activation of extrasynaptic NMDARs occurring during stroke, brain injury, and chronic neurological diseases contributes to neuronal death. Thus, the location of NMDARs determines the neuronal fate. However, the theory is greatly challenged. Several studies suggested that synaptic NMDARs are involved in neuronal death. Recently, our work further showed that the coactivation of synaptic and extrasynaptic NMDARs contributes to neuronal death under neuronal insults. Therefore, we propose that the magnitude and duration of NMDAR activation determines the neuronal fate. More interestingly, there appears to be some subtle differences in the affinity between synaptic and extrasynaptic NMDARs, shedding light on the development of selective drugs to block extrasynaptic NMDARs.