Published online before print May 15, 2003, doi: 10.1161/01.STR.0000075563.45920.24
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(Stroke. 2003;34:e37.)
© 2003 American Heart Association, Inc.
Letters to the Editor |
Dysregulation of the Levels of Matrix Metalloproteinases and Tissue Inhibitors of Matrix Metalloproteinases in the Early Phase of Cerebral Ischemia
Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, New York
To the Editor:
Castellanos et al1 reported increased matrix metalloproteinase (MMP)-9 plasma levels to be an independent risk factor for hemorrhagic transformation in all stroke subtypes. Plasma levels of MMP-9 in patients without hemorrhage were not significantly different from controls, suggesting that MMP-9 does not play an important role in early pathophysiological events in cerebral ischemia. Elevated plasma levels of MMP-9 may therefore play a role in hemorrhagic transformation. Interestingly, similar findings were reported in an animal model of nonhuman primates2: MMP-9 was only significantly increased in subjects with hemorrhagic transformation. Plasma levels of MMP-9 are elevated in such diseases as diabetes,3 carotid artery plaques,4 and atherosclerosis.5 We recently found elevated levels of MMP-9 in the plasma of patients with Alzheimer’s disease.6
We investigated levels of MMPs and tissue inhibitors of MMPs (TIMP) in 24 patients who were admitted with a first episode of cerebral ischemia to the New York Presbyterian Hospital at Weill Cornell Medical Center. Controls were from the outpatient department and were admitted because of headache or seizures. The mean age was not significantly different between the groups (Table). The research ethics committee approved the study, and written informed consent was obtained from all patients (or from family members when necessary). Ten milliliters of blood were collected by venipuncture within 24 hours from the onset of symptoms. Samples were immediately centrifuged at 3000g for 10 minutes and the plasma was stored at -80°C. The gelatinolytic activity of MMP-2 and MMP-9 was evaluated by zymography and TIMP-1 and TIMP-2 by reverse zymography. Additionally, ELISA kits (Amersham Pharmacia, UK) were used to determine the levels of MMP-2, MMP-9, and MMP-8 as well as TIMP-1 and TIMP-2. Differences between groups were tested by the Mann-Whitney test and were considered significant at P<0.05.
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As reported by Castellanos et al,1 levels of MMP-9 in stroke patients were not significantly different from 15 control patients. Levels of MMP-9 did not correlate with infarct size (data not shown) nor with time after onset of stroke (blood drawn between 0.5 hours and 24 hours after stroke). Only 1 patient subsequently had an intracerebral hemorrhage, but this patient had the highest level of MMP-9 on admission (739 ng/mL), further supporting the finding of Castellanos et al.1 We also investigated MMP-2 and MMP-8 as well as the endogenous tissue inhibitors of MMPs, TIMP-1, and TIMP-2 in the plasma samples. Interestingly, MMP-8 plasma levels were significantly reduced in patients with cerebral ischemia as compared with controls. Recently, decreased levels of MMP-8 have been reported in patients with coronary heart failure.7 MMP-8 is able to cleave tissue factor pathway inhibitor, and reduced levels of MMP-8 might increase the endogenous anticoagulant activity as an endogenous regulatory mechanism after cerebral ischemia.
Levels of TIMP-1 were significantly increased in plasma samples from stroke patients as compared with controls. Generally, TIMPs inhibit active MMPs by forming noncovalent stoichiometric complexes within the catalytic site. Several recent reports suggest a role of TIMPs in brain and peripheral nerve injury and repair. TIMPs are induced after kainate-induced excitotoxic seizures in mice.8 TIMP-1 mRNA expression is decreased 2 or 3 days after injury and remains elevated in areas where initial degeneration occurs. Furthermore, TIMP-1 is expressed by Schwann cells and macrophages after sciatic nerve injury in humans.9 These studies indicate that TIMPs, by virtue of their ability to limit the extent of injury-induced matrix proteolysis, may be associated with the remodeling of neuronal circuits after injury. Brain microvascular endothelial cells upregulate TIMP-1 in response to a variety of cytokines, with the strongest effect exerted by the combination of IL-1ß and TNF-
.10 Additionally, TIMP-1 blocks degradation of IL-1ß by several MMPs.11 These cytokines are implicated in neurodegeneration in the early phase of stroke and are frequently found in the plasma of stroke patients. Levels of TIMP-2 in stroke patients were not different from controls. TIMP-2, which is constitutively expressed, is not significantly influenced by cytokines and growth factors.12 This further supports the hypothesis that TIMPs are upregulated in the context of cytokine expression after stroke. In an animal model of stroke, TIMP-2 inhibited MMP-2 activity and reduced proteolytic opening of the blood-brain barrier by MMP-2.13 Therefore the absence of an increase of TIMP-2 in combination with upregulated MMP-9 could also contribute to an increased risk of hemorrhage after cerebral ischemia.
We did not observe differences in MMP-2 expression between stroke patients and controls. Increased levels of MMP-2 have been found after cerebral ischemia in human brain tissue14 at 2 days after stroke, correlating with the poststroke time course of capillary remodeling.
Our findings suggest that there is a delicate change of the levels of matrix degrading proteins (MMPs) and their endogenous counterregulators (TIMPs) in the early phase after cerebral ischemia. Whether these changes contribute to tissue injury or are the result of ischemia needs to be investigated in prospective studies.
References
1. Castellanos M, Leira R, Serena J, Pumar JM, Lizasoin I, Castillo J, Davalos A. Plasma metalloproteinase-9 concentration predicts hemorrhagic transformation in acute ischemic stroke. Stroke. 2003; 34: 40–45.
2. Heo JH, Lucero J, Abumiya T, Koziol JA, Copeland BR, del Zoppo GJ. Matrix metalloproteinases increase very early during experimental focal cerebral ischemia. J Cereb Blood Flow Metab. 1999; 19: 624–633.[CrossRef][Medline] [Order article via Infotrieve]
3. Uemura S, Matsushita H, Li W, Glassford AJ, Asagami T, Lee KH, Harrison DG, Tsao PS. Diabetes mellitus enhances vascular matrix metalloproteinase activity: role of oxidative stress. Circ Res. 2001; 88: 1291–1298.
4. Loftus IM, Naylor AR, Bell PR, Thompson MM. Plasma MMP-9: a marker of carotid plaque instability. Eur J Vasc Endovasc Surg. 2001; 21: 17–21.[CrossRef][Medline] [Order article via Infotrieve]
5. Noji Y, Kajinami K, Kawashiri MA, Todo Y, Horita T, Nohara A, Higashikata T, Inazu A, Koizumi J, Takegoshi T, Mabuchi H. Circulating matrix metalloproteinases and their inhibitors in premature coronary atherosclerosis. Clin Chem Lab Med. 2001; 39: 380–384.[CrossRef][Medline] [Order article via Infotrieve]
6. Lorenzl S, Albers DS, Relkin N, Ngyuen T, Hilgenberg SL, Chirichigno J, Cudkowicz ME, Beal MF. Increased plasma levels of matrix metalloproteinase-9 in patients with Alzheimer’s disease. Neurochem Int. 2003; 43: 191–196.[CrossRef][Medline] [Order article via Infotrieve]
7. Wilson EM, Gunasinghe HR, Coker ML, Sprunger P, Lee-Jackson D, Bozkurt B, Deswal A, Mann DL, Spinale FG. Plasma matrix metalloproteinase and inhibitor profiles in patients with heart failure. J Card Fail. 2002; 8: 390–398.[CrossRef][Medline] [Order article via Infotrieve]
8. Rivera S, Tremblay E, Timsit S, Canals O, Ben-Ari Y, Khrestchatisky M. Tissue inhibitor of metalloproteinases-1 (TIMP-1) is differentially induced in neurons and astrocytes after seizures: evidence for developmental, immediate early gene, and lesion response. J Neurosci. 1997; 17: 4223–4235.
9. La Fleur M, Underwood JL, Rappolee DA, Werb Z. Basement membrane and repair of injury to peripheral nerve: defining a potential role for macrophages, matrix metalloproteinases, and tissue inhibitor of metalloproteinases-1. J Exp Med. 1996; 184: 2311–2326.
10. Bugno M, Witek B, Bereta J, Bereta M, Edwards DR, Kordula T. Reprogramming of TIMP-1 and TIMP-3 expression profiles in brain microvascular endothelial cells and astrocytes in response to proinflammatory cytokines. FEBS Lett. 1999; 448: 9–14.[CrossRef][Medline] [Order article via Infotrieve]
11. Ito A, Mukaiyama A, Itoh Y, Nagase H, Thogersen IB, Enghild JJ, et al. Degradation of interleukin 1beta by matrix metalloproteinases. J Biol Chem. 1996; 271: 14657–14660.
12. Hanemaaijer R, Koolwijk P, le Clercq L, de Vree WJ, van Hinsbergh VW. Regulation of matrix metalloproteinase expression in human vein and microvascular endothelial cells: effects of tumour necrosis factor alpha, interleukin 1 and phorbol ester. Biochem J. 1993; 296: 803–809.[Medline] [Order article via Infotrieve]
13. Rosenberg GA, Kornfeld M, Estrada E, Kelley RO, Liotta LA, Stetler-Stevenson WG. TIMP-2 reduces proteolytic opening of blood-brain barrier by type IV collagenase. Brain Res. 1992; 576: 203–207.[CrossRef][Medline] [Order article via Infotrieve]
14. Clark AW, Krekoski CA, Bou SS, Chapman KR, Edwards DR. Increased gelatinase A (MMP-2) and gelatinase B (MMP-9) activities in human brain after focal ischemia. Neurosci Lett. 1997; 238: 53–56.[CrossRef][Medline] [Order article via Infotrieve]
Response
Department of Neurology, Hospital Universitari Doctor Josep Trueta, Girona, Spain
Department of Neurology, Hospital Clínico Universitario of Santiago de Compostela, Santiago de Compostela, Spain
Department of Neurology, Hospital Universitari Doctor Josep Trueta, Girona, Spain
We very much appreciate the letter by Lorenzl et al regarding to the levels of matrix metalloproteinases (MMPs) in patients with ischemic stroke, as their data further support our own previously published results.1
In a sample of 24 patients with a first episode of ischemic stroke, Lorenzl et al analyze the levels of MMP-2, MMP-9, and MMP-8 as well as the levels of MMP-inhibitors (TIMP-1 and TIMP-2). In accordance with our results, MMP-9 levels on admission are reported to be much higher in the only patient who subsequently developed hemorrhagic transformation of the ischemic tissue, whereas no differences are found between the levels in patients with ischemic stroke compared with control levels, a fact that may be indicating a specific role of MMP-9 in the development of hemorrhagic complications after cerebral ischemia. Levels of MMP-2 and TIMP-2 are also reported to be similar in patients and controls, whereas TIMP-1 levels are reported to be significantly higher in stroke patients. This is in agreement with previous experimental published data that demonstrate an early increase of TIMP-1, which appears at the time of maximal increase of MMP-9 in an attempt to avoid the blood-brain barrier opening, and a later increase of MMP-2 and TIMP-2 in the time course of molecules expression following cerebral ischemia at the time when the repair process begins.2
To our knowledge, no previous data have been previously published about the levels of MMP-8 in cerebral ischemia, which are reported to be significantly lower in stroke patients compared with controls in the report of Lorenzl et al.
MMP release is regulated at the transcriptional level by cytokines and growth factors, which stimulate the synthesis and secretion of pro-MMPs and also their endogenous inhibitors,3,4 so MMP levels may be reflecting the degree of the inflammatory response secondary to different processes. Due to this fact, the control subjects in the Lorenzl et al letter might have not been appropriate, since they studied patients with headache and seizures, in whom an inflammatory reaction cannot be ruled out. A rapid increase of cytokines such as interleukin (IL)-1ß and TNF- has been reported in response to limbic seizures,5 and higher levels of these cytokines have also been demonstrated in patients with some types of headache compared with healthy subjects.6 Moreover, MMP-9 levels have also been reported to be increased after seizures.7
Despite this fact, it is becoming increasingly clear that proteolytic enzymes participate in the pathophysiology of cerebral ischemia, although further and larger studies are still necessary to completely elucidate the role of MMPs and their inhibitors in acute human stroke.
References
1. Castellanos M, Leira R, Serena J, Pumar JM, Lizasoain I, Castillo J, Dávalos A. Plasma metalloproteinase-9 concentration predicts hemorrhagic transformation in acute ischemic stroke. Stroke. 2003; 34: 40–46.
2. Rosenberg GA, Estrada EY, Dencoff JE. Matrix metalloproteinases and TIMPs are associated with blood-brain barrier opening after reperfusion in rat brain. Stroke. 1998; 29: 2189–2195.
3. Ito A, Sato T, Iga T, Mori Y. Tumor necrosis factor bifunctionally regulates matrix metalloproteinase and tissue inhibitor of metalloproteinases (TIMP) production by human fibroblast. FEBS Lett. 1990; 269: 93–95.[CrossRef][Medline] [Order article via Infotrieve]
4. Birkedal-Hansen H, Moore WGL, Boden MK, Windsor LJ, Birkedal-Hansen B, DeCarlo A, Engler JA. Matrix metalloproteinases: a review. Crit Rev Oral Biol Med. 1993; 4: 197–250.
5. Vezzani A, Moneta D, Richichi C, Aliprandi M, Burrows SJ, Ravizza T, Perego C, De Simoni MG. Functional role of inflammatory cytokines and antiinflammatory molecules in seizures and epileptogenesis. Epilepsia. 2002; 43: 30–35.[CrossRef][Medline] [Order article via Infotrieve]
6. Martelletti P. Proinflammatory pathways in cervicogenic headache. Clin Exp Rheumatol. 2000; 18: S33–S38.[Medline] [Order article via Infotrieve]
7. Szklarczyk A, Lapinska J, Rylski M, McKay RD, Kaczmarek L. Matrix metalloproteinase-9 undergoes expression and activation during dendritic remodeling in adult hippocampus. J Neurosci. 2002; 22: 920–930.
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