依達拉奉對于急性腦梗死溶栓患者MMP－9水平及出血性轉(zhuǎn)化的影響

依達拉奉對于急性腦梗死溶栓患者MMP-9水平及出血性轉(zhuǎn)化的影響

陳春燕孫曉江陸學勝

(上海交通大學附屬第六人民醫(yī)院神經(jīng)內(nèi)科，上海200233)

關(guān)鍵詞〔〕依達拉奉;重組組織型纖溶酶原激活物;基質(zhì)金屬蛋白酶-9;出血性轉(zhuǎn)化

中圖分類號〔〕R743.3〔文獻標識碼〕A〔

通訊作者：孫曉江(1955-)，男，教授，主任醫(yī)師，博士生導師，主要從事腦血管病、癲癇等研究。

陸學勝(1965-)，男，主任醫(yī)師，主要從事腦血管病、癲癇等研究。

第一作者：陳春燕(1982-)，女，在讀碩士，主要從事腦血管病研究。

重組組織型纖溶酶原激活物(rt-PA)是美國食品和藥品監(jiān)督管理局(FDA)唯一批準使用于急性缺血性卒中溶栓治療的藥物，時間窗內(nèi)rt-PA靜脈溶栓為目前公認的改善缺血性卒中結(jié)局最有效的治療方法，有效改善血管再通及神經(jīng)功能損傷〔1〕。NINDS〔2〕、亞特蘭蒂斯(ALTLANTIS)以及歐洲協(xié)作急性卒中研究(ECASS)等臨床研究結(jié)果都證明了卒中3 h內(nèi)使用rt-PA靜脈溶栓安全有效〔3〕，ECASSⅢ用13年研究把時間窗擴大到4.5 h〔4〕，然而短暫的時間窗的限制和出血性轉(zhuǎn)化(HT)的風險成了限制溶栓治療最主要的因素，rt-PA溶栓治療出HT概率為非溶栓的10倍〔2，5〕。如何降低出血風險，提高溶栓的療效成為關(guān)注的重點，近年的研究發(fā)現(xiàn)了基質(zhì)金屬蛋白酶(MMP)-9在出HT中的關(guān)鍵作用，而依達拉奉能安全有效地抑制和降低MMP-9水平。

1血腦屏障(BBB)

急性腦梗死rt-PA溶栓后HT，實質(zhì)為BBB的破壞。BBB結(jié)構(gòu)完整可以保護神經(jīng)元的微環(huán)境，主要有三方面組成：腦的連續(xù)毛細血管內(nèi)皮及其細胞間的緊密連接〔6〕、完整的基膜〔7〕、周細胞以及星形膠質(zhì)細胞腳板圍成的神經(jīng)膠質(zhì)膜構(gòu)成，其中內(nèi)皮是BBB的主要結(jié)構(gòu)。急性腦梗死2 h后這些血管內(nèi)皮基底膜結(jié)構(gòu)開始出現(xiàn)損傷〔8〕，當內(nèi)皮和緊密連接蛋白受到破壞及基底膜遭降解損傷后，BBB的完整性破壞，炎癥因子和液體等滲入腦組織，引起細胞死亡，腦水腫和出血性轉(zhuǎn)化。這種情況在老年人反應和損傷比中年人更為嚴重〔9〕。研究發(fā)現(xiàn)MMP-9在腦代謝的病理生理過程中尤其是HT、BBB的破壞起了很關(guān)鍵的作用〔10〕。MMP-9可以水解細胞內(nèi)皮細胞內(nèi)緊密連接蛋白結(jié)構(gòu)而損傷BBB〔11〕，MMP-9缺乏的小鼠表現(xiàn)較少的BBB裂開和腦損傷〔12〕。

正常腦組織中MMP-9無表達或少量表達〔13〕，缺血再灌注后MMP-9水平迅速升高〔14〕，溶栓后 MMP-9表達上調(diào)的原因可能與下列因素有關(guān)：(1)缺血再灌注誘發(fā)炎癥反應，產(chǎn)生大量炎性因子和介質(zhì)誘導MMP-9生成〔15〕，(2)氧化應激產(chǎn)生大量自由基〔16〕，促進MMP-9表達〔17〕并損傷微血管導致血管破裂，用自由基清除劑可減少t-PA引起的出血，(3)rt-PA能激活MEK，并進一步使ERK磷酸化而活化，從而促進MMP-9基因的表達〔18〕，(4)rt-PA為纖溶酶原激活劑，其纖維蛋白在MMP-9的激活過程中起了重要作用，從而使MMP-9表達增加，對腦血管的基底膜降解作用進一步增強而引起HT〔19〕。

體外研究發(fā)現(xiàn)rt-PA可誘導血管內(nèi)皮細胞MMP-9的表達〔20〕，臨床試驗發(fā)現(xiàn)rt-PA溶栓后MMP-9大量表達〔21〕，McColl等〔13〕報道rt-PA溶栓后MMP-9活性進一步增加，而對照組未見有MMP-9活性的改變。第一項研究顯示在人類大腦卒中后MMP-9的升高是由Clark等〔22〕完成的，表明腦梗后2 d的人類大腦組織MMP-9活動較沒有腦梗的明顯提高。隨后臨床研究資料證實MMP-9在卒中的關(guān)鍵因素和再灌注期間其有害影響〔21〕，MMPs家族中僅僅MMP-9表達顯著增加與HT換的主題相關(guān)〔23〕。一項擴大實驗327名溶栓患者(年齡68.9±12.1，NIHSS平均11分)，檢測所有MMPS家族(1,2,3,7,8,9)發(fā)現(xiàn)僅MMP-9有明顯變化，與HT和死亡率相關(guān)〔24〕，Mallolas等〔25〕發(fā)現(xiàn)基線水平的MMP-9升高是靜脈內(nèi)使用rt-PA治療造成腦出血的獨立預測因素，MMP-9可以作為生化標志物預測溶栓后HT〔26〕。最近的數(shù)據(jù)證實高MMP-9水平不僅在梗死組織還在臨近組織區(qū)域,這表明MMP-9參與梗死區(qū)域擴大的過程〔27〕，高水平的MMP-9明顯和腦梗死體積大、程度嚴重及預后差相關(guān)〔28〕，在急性腦梗死死亡患者中MMP-9 mRNA的濃度為存活者的3倍〔29〕，因此MMP-9 mRNA是卒中患者預后差、死亡率高的預測值。第一個研究MMP-9敲除小鼠(KO)模型以來均顯示MMP-9 KO小鼠運動缺陷低于野生型(WT)小鼠〔30〕，在MMP-9局灶腦缺血模型KO小鼠顯示顯著的BBB的保護〔31〕，由此可以推測MMP-9對BBB的損傷引起HT。

3依達拉奉與rt-PA聯(lián)合治療急性腦梗死

如何安全有效地抑制MMP-9的生成及降低其水平成為了一個研究目標，了解到在缺血及再灌注損傷過程中，始終相關(guān)的一項作用因素即為氧化應激，產(chǎn)生大量炎癥因子反應，生成大量自由基〔32〕及促進MMP-9水平升高〔33〕，導致血管神經(jīng)單元損傷，破壞血腦屏障，甚至出血轉(zhuǎn)化〔34〕。依達拉奉作為有效的腦保護劑應運而生。依達拉奉的獲益首先在日本被報道〔35〕，1993年～2008年出版了Lapchak致力于藥物的臨床療效和毒理學的文獻評論的研究，證實依達拉奉的作用和應用前景〔36〕。2001年依達拉奉被日本衛(wèi)生部、勞工與福利局認可作為自由基清除與神經(jīng)保護劑，24 h內(nèi)使用可以改善神經(jīng)功能癥狀，日常生活能力及臨床預后〔37〕，2009年寫進卒中管理指南作為B級推薦，亦被美國心臟病學會(AHA)組織指南推薦為急性腦梗死早期用藥。

依達拉奉是具有水和脂溶性屬性的小分子基團，BBB的通透率是60%，靜脈給藥后靜滴10 min達血藥濃度，清除腦內(nèi)具有高度細胞毒性的羥基基團〔38〕，可抑制脂質(zhì)過氧化作用〔39〕，減輕腦缺血和腦缺血引起的腦水腫及組織損傷〔40〕，防止梗死灶擴大、減少遲發(fā)性腦細胞死亡〔41〕，改善神經(jīng)功能〔42〕。rt-PA溶栓患者依達拉奉亦能降低血MMP-9濃度〔43〕，改善早期血管再通〔44〕，降低出溶栓后HT〔45〕，降低溶栓相關(guān)神經(jīng)毒性作用〔46〕。

依達拉奉聯(lián)合溶栓治療首先由Yoshida等〔47〕提出，他們發(fā)現(xiàn)由溶栓治療引起的出血性事件可能會被依達拉奉降低，因此他們認為治療有助于減少卒中的死亡率和改善神經(jīng)功能缺損。近期一項小鼠動物模型實驗發(fā)現(xiàn)依達拉奉聯(lián)合t-PA溶栓治療起到協(xié)同作用、增進t-PA效果，減少HT，提高生存率，改善神經(jīng)功能，增強再灌注〔48〕。研究發(fā)現(xiàn)rt-PA聯(lián)合依達拉奉治療發(fā)現(xiàn)能明顯改善預后，隨后Kono等〔49〕將研究擴大到129例亦發(fā)現(xiàn)同樣效果，Wada等〔50〕認為依達拉奉聯(lián)合rt-PA改善早期臨床癥狀，有效改善血管再通和HT〔51〕,可作為預防HT用藥。大型研究看出，聯(lián)合依達拉奉的溶栓癥狀性出血率遠遠低于未聯(lián)合依達拉奉者〔52～54〕。目前日本正在大規(guī)模開展YAMATO(the tPA and Edaravone Combination Therapy study—a multiple stroke center trial)研究，旨在發(fā)現(xiàn)溶栓同時使用依達拉奉使得再通率增高，減少出血并發(fā)癥或者改善預后。

4總結(jié)與展望

依達拉奉能夠有效安全的抑制MMP-9的水平，此前的研究大部分為溶栓后數(shù)小時后開始使用依達拉奉，而相關(guān)研究表明溶栓前或溶栓同時使用效果更佳，目前的資料尚少，待更多研究以便推廣。

5參考文獻

1重組組織型纖溶酶原激活劑靜脈溶栓治療缺血性卒中共識專家組〔J〕.重組組織型纖溶酶原激活劑治療急性缺血性卒中中國專家共識.中華內(nèi)科學雜志,2012;51(12):1006-10.

2Tissue plasminogen activator for acute ischemic stroke.The national institute of neurological disorders and stroke rt-PA stroke study group〔J〕.N Engl J Med,1995；333(24):1581-7.

3Hacke W,Donnan G,Fieschi C,etal.Association of outcome with early stroke treatment:pooled analysis of ALTLANTIS,ECASS,and NINDS rt-PA stroke trials〔J〕.Lancet,2004；363(9411):768-4.

4Hacke W,Kaste M,Bluhmki E,etal.Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke〔J〕.Nengl J Med,2008;359(13):1317-29.

5Kidwell CS,Latour L,Saver JL,etal.Thrombolytic toxicity:blood brain barrier disruption in human ischemic stroke〔J〕.Cerebrovasc Dis,2008；25(4):338-43.

6Yang Y,Rosenberg GA.MMP-mediated disruption of claudin-5 in the blood-brain barrier of rat brain after cerebral ischemia〔J〕.Methods Mol Biol,2011;762(3):333-45.

7Rosenberg GA.Matrix metalloproteinases in neuroinflammation〔J〕.Glia,2002;39(3):279-91.

8Hamann GF，Liebetrau M，Martens H，etal.Microvascular basal lamina injury after experimental focal cerebral ischemia and reperfusion in the rat〔J〕.Cereb Blood Flow Metab,2002;22(5):526-33.

9Lee P,Kim J,Williams R,etal.Effects of aging on blood brain barrier and matrix metalloproteases following controlled cortical impact in mice〔J〕.Exp Neurol,2012;234(1):50-61.

10Moskowitz MA,Lo EH,Iadecola C.The science of stroke:mechanisms insearch of treatments〔J〕.Neuron,2010;67(2):181-98.

11Witt KA，Mark KS，Hom S，etal.Effects of hypoxia-reoxygenation on rat blood-brain barrier permeability and tight junctional protein expression 〔J〕.Am J Physiol Heart Circ Physiol,2003；285(6):2820-31.

12Svedin P，Hagberg H，Savman K，etal.Matrix metalloproteinase-9 gene knock-out protects the immature brain after cerebral hypoxia-ischemia 〔J〕.Neurosci,2007；27(7):1511-8.

13McColl BW,Rothwell NJ,Allan SM.Systemic inflammation alters the kinetics of cerebro vascular tight junction disruption after experimental stroke in mice〔J〕.J Neurosci,2008；28(38):9451-62.

14Ning M,Furie KL,Koroshetz WJ.Association between tPA therapy and raised early matrix metalloproteinase-9 in acute stroke〔J〕.Neurology,2006；66(10):1550-5.

15Gottschall PE,Yu X.Cytokines regulate gelatinase A and B (matrix metalloproteinase 2 and 9) activity in cultured rat astrocytes〔J〕.Neurochem,1995；64(4):1513-20.

16Kelly PJ,Morrow JD,Ning M,etal.Oxidative stress and matrix metalloproteinase-9 in acute ischemic stroke:the Biomarker Evaluation for Antioxidant Therapies in Stroke (BEAT-Stroke) study〔J〕.Stroke,2008,39(1):100-4.

17Yamashita T,Abe K.Therapeutic approaches to vascular protection in ischemic stroke〔J〕.Acta Med Okayama,2011；65(4):219-23.

18Liu W,Hendren J.Normobaric hyperoxia reduces the neurovascular complications associated with delayed tissue plasminogen activator treatment in a rat model of focal cerebral ischemic〔J〕. Stroke,2009;40(7):2526-31.

19Lukic-Panin V,Deguchi K,Yamashita T,etal.Free radical scavenger edaravone administration protects against tissue plasminogen activator induced oxidative stress and blood brain barrier damage〔J〕.Curr Neurovasc Res,2010；7(4):319-29.

20Wang X,Lee S R,Arai K,etal,Lipoprotein receptor-mediated induction of matrix metalloproteinase by tissue plasminogen activator〔J〕.Nat Med,2003；9(10):1313-7.

21Horstmann S,Kalb P,Koziol J,etal.Profiles of matrix metalloproteinases,their inhibitors,and laminin in stroke patients:influence of different therapies〔J〕.Stroke,2003;34(9):2165-70.

22Clark AW,Krekoski CA,Bou SS,etal.Increased gelatinase A (MMP-2) and gelatinase B (MMP- 9) activities in human brain after focal ischemia〔J〕.Neurosci Lett,1997,238(1-2):53-6.

23Maddahi A,Chen Q,Edvinsson L.Enhanced cerebrovascular expression of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 via the MEK/ERK pathway during cerebral ischemia in the rat〔J〕.BMC Neurosci,2009；10(1):56.

24Inzitari D,Giusti B,Nencini P,etal.MMP9 variation after thrombolysis is associated with hemorrhagic transformation of lesion and death〔J〕.Stroke,2013;44(10):2901-3.

25Mallolas J,Rodr′guez R,Gubern C,etal.A Polymorphism in the promoter region of the survivin gene is related to hemorrhagic transformation in patients with acute ischemic stroke〔J〕.Neuromol Med,2014;16(4):856-61.

26Brouns R,Wauters A,De Surgeloose D,etal.Biochemical markers for blood-brain barrier dysfunction in acute ischemic stroke correlate with evolution and outcome〔J〕.Eur Neurol,2011;65(1):23-31.

27Morancho A,Rosell A,Garcia-Bonilla L,etal.Metalloproteinase and stroke infarct size:role for anti-inflammatory treatment 〔J〕.Ann N Y Acad Sci,2010;1207(2):123-33.

28Ramos-Fernandez M,Bellolio MF,Stead LG.Matrix metalloproteinase-9 as a marker for acute ischemic stroke:a systematic review〔J〕.J Stroke Cerebrovasc Dis,2011;20(1):47-54.

29Graham CA,Chan RW,Chan DY,etal.Matrixmetalloproteinase9 mRNA:a nearly prognostic marker for patients with acute stroke〔J〕.Clin Biochem,2012;45(4-5):352-5.

30Wang X,Jung J,Asahi M,etal.Effects of matrix metalloproteinase-9 gene knock-out on morphological and motor outcomes after traumatic brain injury〔J〕.J Neurosci,2000;20(18):7037-42.

31Asahi M,Wang X,Mori T,etal.Effects of matrix metalloproteinase-9 gene knock-out on the proteolysis of blood-brain barrier and whit ematter components after cerebral ischemia〔J〕.Neurosci,2001;21(19):7724-32.

32Zhang W,Sato K,Hayashi T,etal.Extension of ischemic therapeutic time window by a free radical scavenger,Edaravone,reperfused with tPA in rat brain〔J〕.Neurol Res,2004;26(3):342-8.

33Miyamoto N,Pham LD,Maki T,etal.A radical scavenger edaravone inhibits matrix metalloproteinase-9 upregulation and blood-brain barrier breakdown in a mouse model of prolonged cerebral hypoperfusion〔J〕.Neurosci Let,2014;573(1):40-5.

34Chaturvedi M,Kaczmararek L.MMP-9 inhibition:a therapeutic strategy in ischemic stroke〔J〕.Mol Neurobiol,2014;49(1):563-73.

35Abe K,Yuki S,Kogure K.Strong attenuation of ischemic and post ischemic brain edema in rats by a novel free radical scavenger〔J〕.Stroke,1988;19(4):480-5.

36Lapchak PA.A critical assessment of edaravone acute ischemic stroke efficacy trials:is edaravone an effective neuroprotective therapy〔J〕.Expert Opin Pharmacother,2010;11(10):1753-63.

37Edaravone Acuccte Infarction Study Group.Effect of a novel free radical scavenger, edaravone(MCI-186), on acute brain infarction. Randomized, placebo-controlled, double-blind study at multicenters〔J〕.Cerebrovasc Dis, 2003;15(3):222-9.

38Watanabe T,Tahara M,Todo S.The novel antioxidant edaravone:from bench to bedside〔J〕.Cardiovasc Ther,2008;26(5):101-14.

39Ahmad A,Khan MM,Javed H,etal.Edaravone ameliorates oxidative stress associated cholinergic dysfunction and limits apoptotic response following focal cerebral ischemia in rat〔J〕.Mol Cell Biochem,2012;367(1-2):215-25.

40Toyoda K,Fujii K,Kamouchi M,etal.Free radical scavenger,edaravone,in stroke with internal carotid artery occlusion 〔J〕.J Neurol Sci,2004;221(1-2):11-7.

41Yoshida H,Mimura J,Imaizumi T,etal.Edaravone camosic caid synergistically euhance the expression of nerve and growth factor in human astrocytes under hypoxia/reoxygenation〔J〕.Neurosci Res,2011;69(4):291-8.

42Sharma P,Sinba M,Shukla R,etal.A randomized controlled clinical trial to compare the safety and efficacy of edaravone in acute ischemic stroke〔J〕.Ann Indian Acad Neurol,2011;14(2):103-6.

43Isahaya K,Yamada K,Yamatoku M,etal.Effects of edaravone,a free radical scavenger,on serum levels of inflammatory biomarkers in acute brain infarction〔J〕.J Stroke Cerebrovasc Dis,2012;21(2):102-7.

44Kimura K,Aoki J,Sakamoto Y,etal.Administration of edaravone,a free radical scavenger,during t-PA infusion can enhance early recanalization in acute stroke patients -A preliminary study〔J〕.J Neurol Sci,2012;333(1-2):132-6.

45Yamashita T,Kamiya T,Deguchi K,etal.Dissociation and protection of the neurovascular unit after thrombolysis and reperfusion in ischemic rat brain〔J〕.J Cereb Blood Flow Metab,2009;29(4):715-25.

46Lukic-Panin V,Deguchi K,Yamashita T,etal.Free radical scavenger edaravone administration protects against tissue plasminogen activator induced oxidative stress and blood brain barrier damage〔J〕.Curr Neurovasc Res,2010;7(4):319-29.

47Yoshida H,Yanai H,Namiki Y,etal.Neuroprotective effects of edaravone:a novel free radical scavenger in cerebrovascular injury〔J〕.CNS Drug Rev,2006;12(1):9-20.

48Sun YY,MorozovYM,Yang D，etal.Synergy of combined tPA-Edaravone therapy in experimental thrombotic stroke〔J〕.PLoS Done,2014;9(6):e98807.

49Kono S,Deguchi K,Morimoto N,etal.Intravenous thrombolysis with neuroprotective therapy by edaravone for ischemic stroke patients older than 80 years of age〔J〕.J Stroke Cerebrovasc Dis,2013;22(7):1175-83.

50Wada T,Yasunaga H,Inokuchi R,etal.Effects of edaravone on early outcomes in acute ischemic stroke patients treated with recombinant tissue plasminogen activator〔J〕.J Neurol Sci,2014;345(1-2):106-11.

51Takenaka K,Kato M,Yamauti K,etal.Simultaneous administration of recombinant tissue plasminogen activator and edaravone in acute cerebral ischemic stroke patients〔J〕.J Stroke Cerebrovasc Dis,2014;23(10):2748-52.

52Wahlgren N,Ahmed N,Eriksson N,etal.Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials:Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST)〔J〕.Stroke,2008;39(12):3316-22.

53Nakagawara J,Minematsu K,Okada Y,etal.Thrombolysis with 0.6 mg/kg intravenous alteplase for acute ischemic stroke in routine clinical practice:the Japan Post-Marketing Alteplase Registration Study (J-MARS) 〔J〕.Stroke,2010;41(9):1984-9.

54Mori E,Minematsu K,Nakagawara J,etal.Effects of 0.6 mg/kg intravenous alteplase on vascular and clinical outcomes in middle cerebral artery occlusion:Japan Alteplase Clinical Trial Ⅱ (J-ACT Ⅱ) 〔J〕.Stroke,2010;41(3):461-5.

〔2015-03-15修回〕

(編輯袁左鳴)