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(Stroke. 2004;35:2064.)
© 2004 American Heart Association, Inc.

Original Contributions

Association of Polymorphisms and Haplotypes in the Elastin Gene in Dutch Patients With Sporadic Aneurysmal Subarachnoid Hemorrhage

Y.M. Ruigrok, MD; U. Seitz, BSc; S. Wolterink, BSc; G.J.E. Rinkel, MD, FAHA; C. Wijmenga, PhD Z. Urbán, PhD

From the Department of Neurology (Y.M.R., G.J.E.R.), Rudolf Magnus Institute of Neuroscience, the Netherlands; the Department of Biochemistry (U.S., S.W., Z.U.), John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; and the Department of Biomedical Genetics (C.W.), University Medical Center Utrecht, the Netherlands.

Correspondence to Dr Z. Urbán, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid, Box 8208, St. Louis, MO 63110. E-mail urban_z{at}kids.wustl.edu

	Abstract

Top Abstract Introduction Patients and Methods Results Discussion References

 
Background and Purpose— A locus containing the elastin gene has been linked to familial intracranial aneurysms in 2 distinct populations. We investigated the association of single-nucleotide polymorphisms (SNPs) and haplotypes of SNPs in the elastin gene with the occurrence of subarachnoid hemorrhage (SAH) from sporadic aneurysms in the Netherlands.

Methods— We genotyped 167 SAH patients and 167 matching controls for 18 exonic and intronic SNPs in the elastin gene. A Bonferroni correction was applied for multiple comparisons with all novel associations, with a correction factor derived from the number of SNPs tested (P value after Bonferroni correction [P_corr]).

Results— SAH was statistically significant associated with an SNP in exon 22 of the elastin gene (minor allele frequency was 0.000 in patients and 0.028 in controls; odds ratio [OR], 0.0; 95% CI, 0.0 to 0.7; P=0.004; P_corr=0.05) and possibly with an SNP in intron 5 (minor allele frequency was 0.062 in patients and 0.128 in controls; OR, 0.5; 95% CI, 0.2 to 0.8; P=0.007; P_corr=0.08). Haplotypes of intron 5/exon 22 (P_corr=0.002), intron 4/exon 22 (P_corr=0.02), and intron 4/intron 5/exon 22 (P=9.0x10^–9) were also associated with aneurysmal SAH.

Conclusions— Variants and haplotypes within the elastin gene are associated with the risk of sporadic SAH in Dutch patients. Gradual increase of statistical power with the inclusion of 2 or 3 SNPs in the studied haplotypes supports the validity of our conclusion that the elastin gene is a susceptibility locus for SAH.

Key Words: aneurysm • extracellular matrix • genetics, human • risk factors • subarachnoid hemorrhage

	Introduction

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Genetic factors are likely to be involved in the development of intracranial aneurysms (IAs) because familial predisposition is the strongest risk factor for aneurysmal subarachnoid hemorrhage (SAH).^1,2 Familial clustering is found in 10% of patients with SAH, and first-degree relatives of patients with SAH have a 3 to 7x greater risk of developing SAH than the general population.¹

In many ruptured IAs, the arterial wall contains reduced amounts of extracellular matrix proteins.^3,4 Elastin is an important structural protein of this extracellular matrix and is mainly confined to the internal elastic lamina in intracranial arteries.⁵ Elastin has been proposed as a functional candidate gene for IA because defects in the internal elastic lamina have been found in IAs.^6–8 Recently, elastin has also been suggested to be a positional candidate gene for familial IA because a genome-wide and a locus-specific linkage study in affected sib pairs and affected pedigree members, respectively, showed linkage to a region on chromosome 7q11 that includes the elastin gene.^9,10 The gene was analyzed further for allelic and haplotype associations in a sample with equal numbers of sporadic and familial patients with SAH from Japan.⁹ Although no allelic association was found with any of the 14 single-nucleotide polymorphisms (SNPs) investigated in the elastin gene, the haplotype constructed from the intron 20 (INT 20) and INT 23 polymorphisms was strongly associated with IA (P=3.81x10^–6),⁹ which further supported a locus for IA within or near the elastin gene. However, an additional genome-wide and a locus-specific linkage study of IA failed to provide positive results for 7q11.^11,12 Furthermore, the INT 20/INT 23 haplotype was not associated with IA in a sample from Central Europe.¹³ To investigate the role of the elastin gene in sporadic SAH patients further, we studied the association of 18 exonic and intronic SNPs, including the 14 SNPs analyzed previously,⁹ and haplotypes of pairwise combinations of these SNPs in the elastin gene with sporadic, aneurysmal SAH in the Dutch population.

	Patients and Methods

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Patient and Control Recruitment
We included 167 consecutive Dutch patients with sporadic aneurysmal SAH admitted to the University Medical Center Utrecht and 167 age- and sex-matched Dutch controls. Patients with aneurysmal SAH were defined by symptoms suggestive of SAH combined with subarachnoid blood on computed tomography (CT) and a proven aneurysm on CT angiography or conventional angiography. The matched controls were selected from the database of the Department of Medical Genetics, which includes healthy family members of patients with diverse diseases. The ethical review board of our hospital approved our study protocol.

Polymorphisms in the Elastin Gene
We analyzed 18 exonic and intronic SNPs (Table 1), of which 14 were analyzed previously in Japanese SAH patients.⁹ We also included 4 previously published SNPs¹⁴ and 1 SNP from the SNP database (ID rs2229427). Furthermore, a tetranucleotide repeat polymorphism within INT 1^9,15 was analyzed because this polymorphism showed allelic association with aneurysmal SAH in a previous study.⁹ A map of the elastin gene with informative polymorphisms is shown in Figure 1.

View this table: [in this window] [in a new window]   TABLE 1. Characteristics of the Analyzed Polymorphisms in the Elastin Gene

View larger version (12K): [in this window] [in a new window]   Figure 1. Location of informative polymorphisms in the elastin gene. Location of informative polymorphisms investigated in this study is shown by tie lines to a schematic representation of the elastin gene. The promoter region, introns, and 3'-untranslated region (3'-UTR) of the elastin gene are shown by solid lines. Exons are indicated by boxes on the basis of the nature of domains encoded. Open boxes indicate hydrophobic domains; full boxes, cross-link domains; hatched boxes, signal peptide and C-terminal cysteine-containing domains. Exons subject to alternative splicing in dermal fibroblasts (Z. Urbán et al, unpublished data, 2004) are indicated by asterisks. Different scaling was used for drawing exons and introns as indicated by scale bars below the diagram.

Laboratory Analyses
Genotyping of SNPs in the elastin gene was performed with coded genomic DNA samples using a multiplex fluorescent primer extension assay.¹⁶ For all reactions, we used no template negative controls and sequence-confirmed positive controls for each available genotype. Assay conditions are available upon request. Genotyping results were verified by review of the chromatograms by 2 independent observers. Discordant or missing genotype calls were subjected to genotyping by direct sequence analysis of both strands. The tetranucleotide repeat polymorphism within INT 1 was detected by polymerase chain reaction.¹⁵

Statistical Analysis
Statistical analysis of the haplotype frequency and linkage disequilibrium (LD) calculations were conducted using the COCAPHASE option of the software UNPHASED v2.402 which uses likelihood ratio tests in a log-linear model.¹⁷ The calculated LD statistics included global D' and Pearson ² tests.¹⁸ Differences in allele frequencies of each SNP between patients and controls were assessed as an odds ratio (OR) of the minor allele with a corresponding 95% CI and P value using the major allele as reference. In analyzing haplotypes, the OR of the most frequent haplotype for a given combination of SNPs was assessed by using the remaining haplotypes as reference. A Bonferroni correction (a multiple-comparison correction) was applied to all significant associations, with a correction factor derived from the number of SNPs or haplotypes tested (P value after Bonferroni correction [P_corr]). For the tetranucleotide repeat polymorphism in INT 1, differences in allele frequencies between patients and controls were compared using ² test comparing only alleles with frequencies 5.0%. Our study was performed in a paired fashion. Therefore, data were analyzed only if genotypes were available for both individuals in a patient-control pair. Tests for Hardy–Weinberg equilibrium were conducted using ² tests.

Assuming a recessive disease locus,⁹ our cohort of 167 cases and 167 controls had an 80% power to detect a susceptibility locus with a relative risk of 1.2 at a significance level of 0.05 when testing SNPs with minor allele frequencies of 0.025 (genetic power calculator; SGDP Statistical Genetics Group).

	Results

Top Abstract Introduction Patients and Methods Results Discussion References

 
The SNPs PM1, PM2, PM3, exon 5 (EX 5), INT 14, and EX 20-1 were not polymorphic in our population. Distribution of the genotypes of the remaining 12 SNPs and the tetranucleotide repeat polymorphism was consistent with Hardy–Weinberg equilibrium (Table 2).

View this table: [in this window] [in a new window]   TABLE 2. SNP Genotype and Allele Frequencies in Patients With Aneurysmal SAH vs Controls

SAH Association With Elastin Gene Alleles
We compared allele frequencies of the remaining 12 polymorphic SNPs between patients and controls (Table 2). The EX 22 SNP was associated with aneurysmal SAH because 0% of the patients were carriers of the minor allele compared with 2.8% of the controls (OR, 0.0; 95% CI, 0.0 to 0.7; P=0.004). After Bonferroni correction, the association remained statistically significant (P_corr=0.05). The INT 5 SNP showed association with aneurysmal SAH with 6.2% carriers of the minor allele in the patient group versus 12.8% in the control group (OR, 0.5; 95% CI, 0.2 to 0.8; P=0.007). After applying Bonferroni correction, this P value was no longer statistically significant (P_corr=0.08). The remaining 10 SNPs were not associated with aneurysmal SAH. Allele frequencies of the tetranucleotide repeat polymorphism in INT 1 were not significantly different in patients with aneurysmal SAH and controls (P=0.37; 4 df; data not shown).

SAH Association With Elastin Gene Haplotypes
We constructed haplotypes using all 21 possible pairwise SNP combinations that included SNPs EX 22 and INT5. Haplotype association with SAH was found for all haplotypes involving SNP EX 22 and almost all haplotypes involving SNP INT 5 (except for INT5/INT6, INT5/INT8, and INT5/INT23). After Bonferroni correction, association with haplotypes of INT5/EX22 remained statistically significant (P_corr=0.002; Table 3). The G,G haplotype (major alleles for both INT5 and EX22) was more prevalent in patients than in controls (OR, 2.6; 95% CI, 1.2 to 5.8). In addition, association with haplotypes of INT4/EX22 also remained significant after correction (P_corr=0.02; Table 3). The G,G haplotype (major alleles for INT4 and EX22) was also more prevalent in patients than in controls (OR, 2.8; 95% CI, 1.5 to 5.4). As expected, haplotypes of SNP combination INT4/INT5/EX22 were even more strongly associated with SAH (P=9.0x10^–9) with the G,G,G haplotype being more prevalent in patients than in controls (90% versus 76%; OR, 2.9; 95% CI, 1.7 to 4.8).

View this table: [in this window] [in a new window]   TABLE 3. Association Study With Haplotypes Consisting of Pairwise Combination of Alleles of SNPs EX 22, INT4, and INT 5 in SAH Patients vs Controls

LD Pattern Within the Elastin Gene
Because many SNPs in the elastin gene have relatively low minor allele frequencies, many LD analyses showed high P values. In our LD analyses, we only show the results with a P value 0.05 (Figure 2). Pairwise analysis showed an irregular pattern of LD between SNPs in the control patients with an overall weak LD (Figure 2). A possible ancestral haplotype INT20/INT23/INT32/3UTR did not show haplotype association in patients with aneurysmal SAH and controls. The LD pattern was similar in controls and SAH patients (data not shown).

View larger version (33K): [in this window] [in a new window]   Figure 2. Pairwise LD between SNPs in the elastin gene in control individuals. D' value is a measure of LD with values between 0 and 1; D' values between 0.7 and 1.0 are considered to be an evidence of LD. Shading indicates D'>0.70 and P<0.05.

	Discussion

Top Abstract Introduction Patients and Methods Results Discussion References

 
In a series of Dutch patients with sporadic aneurysmal SAH, we found a significant association with an SNP EX22 with more carriers of the minor allele in the control group. An explanation for this finding may be that the minor allele or an allele in disequilibrium with it is protective of SAH. Furthermore, we found that the haplotypes INT5/EX22, INT4/EX22, and haplotype INT4/INT5/EX22 also showed significant association with aneurysmal SAH. Gradual increase of statistical power with the inclusion of 2 or 3 SNPs in the studied haplotypes supports the validity of our conclusion that the elastin gene is a susceptibility locus for SAH.

Allele frequencies of the elastin gene differ between Dutch and Japanese populations.⁹ Six of the SNPs described in the Japanese patients were not polymorphic in the Dutch population. Moreover, the association of aneurysmal SAH with the haplotype between the INT 20/INT 23 polymorphism and the (CCTT) repeat microsatellite in INT 1 of the elastin gene⁹ was not confirmed in our study. Differences in study populations may in part explain the differences found. We only included patients without a known positive family history for IA, whereas the Japanese study population consisted of 50% of patients with a positive family history. In addition, we used a clinically homogeneous population of only patients with aneurysmal SAH, whereas the Japanese study included not only patients with aneurysmal SAH but also patients with unruptured IA. Another explanation for the differences between the studies is that historical isolation has led to different allele frequencies and haplotype structure across populations.¹⁹ If this is true, population-specific variants may contribute to the risk of SAH and IA. Such variations may, for example, play a role in the difference in SAH incidence, which is 3x higher in Japan (and in Finland) than in other parts of the world.^20,21

Our results also replicate the findings that in 30 familial and 175 sporadic SAH patients from Central Europe, no allellic association of the haplotype between the INT 20/INT 23 polymorphism was found.¹³ These authors also suggested allelic heterogeneity between Japanese and European populations of SAH patients. Further indication of possible population differences is that linkage to chromosome 7q11 demonstrated in Japanese⁹ and North American¹⁰ SAH patients was not confirmed in 2 other linkage-mapping studies.^11,12

A strength of our study was that we used patient-control pairs matched by age and sex to minimize differences in SAH risk between cases and controls. In addition, to prevent genotyping bias, the study was conducted in a blinded fashion. We investigated a large number of SNPs, which increase the risk of finding a false-positive association of a genotype with aneurysmal SAH by chance. However, in this study, analyses with a large number of SNPs were necessary because LD between the SNPs was generally low. Furthermore, we applied a Bonferroni correction to all novel associations to reduce the risk of finding false-positive associations.

The analyzed SNPs in the elastin gene did not show strong LD. These results are consistent with the LD analysis in the Japanese population, in which the LD for SNPs in the elastin gene was also very weak.⁹ Boundaries between haplotype blocks correlate with meiotic recombination hot spots.²² Although recombination rates within the elastin gene locus have not been investigated directly, a previous report of a de novo recombination between 2 mutations in the elastin gene²³ suggested that the elastin gene may be a recombination hot spot, which would explain the lack of LD in this locus.

The elastin protein consists of lysine-rich cross-linking domains and hydrophobic domains responsible for elastic properties. The domain structure of the protein is a reflection of the exon organization of the gene because the hydrophobic and cross-linking domains are encoded by separate exons. The primary transcript of the gene is alternatively spliced.^24,25 Exonic SNPs or intronic polymorphisms located close to exons may alter efficiency of the splicing and thus change the domain content of the resulting polypeptide. SNPs INT4, INT5, and EX22 are flanking or are located within such alternatively spliced exons. Altered domain content of the corresponding elastin may confer resistance to the pathogenic mechanism leading to IA rupture.

	Acknowledgments

 
Y.M. Ruigrok was supported by the Netherlands Organization for Scientific Research (project No. 940-37-023). This work was also supported in part by an established clinical investigator grant from the Netherlands Heart Foundation to G.J.E. Rinkel (D98.014), an American Heart Association grant (0150587 N), and core support from National Institutes of Health grant RR03061 to Z.U. Technical help and suggestions regarding the genotyping assays by Marc W. Crepeau and regarding the statistical analysis of haplotypes by Bobby Koeleman are gratefully acknowledged.

Received December 5, 2003; revision received May 10, 2004; accepted June 22, 2004.

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Top Abstract Introduction Patients and Methods Results Discussion References

 

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This Article Abstract Full Text (PDF) All Versions of this Article: 35/9/2064    most recent 01.STR.0000139380.50649.5cv1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ruigrok, Y.M. Articles by Urbán, Z. Search for Related Content PubMed PubMed Citation Articles by Ruigrok, Y.M. Articles by Urbán, Z. Related Collections Clinical genetics Genetics of cardiovascular disease Acute Cerebral Hemorrhage Cerebral Aneurysm, AVM, & Subarachnoid hemorrhage Genetics of Stroke Risk Factors for Stroke