J Neurosurg 99:65–70, 2003

Matrix metalloproteinase–9 concentration after spontaneous

intracerebral hemorrhage

SÒNIA ABILLEIRA, M.D., PH.D., JOAN MONTANER, M.D., PH.D.,

CARLOS A. MOLINA, M.D., PH.D., JASONE MONASTERIO, M.D., PH.D.,
JOSÉ CASTILLO, M.D., PH.D., AND JOSÉ ALVAREZ-SABÍN, M.D., PH.D.
Neurovascular Unit, Department of Neurology and Hematologic Research Unit, Hospital General
Vall d’Hebron, Barcelona; and the Department of Neurology, Hospital Clínico Universitario,
Santiago de Compostela, Spain

Object. Matrix metalloproteinases (MMPs) are overexpressed in the presence of some neurological diseases in
which blood–brain barrier disruption exists. The authors investigated the MMP-9 concentration in patients after acute
intracerebral hemorrhage (ICH) and its relation to perihematomal edema (PHE).
Methods. Concentrations of MMP-9 and related proteins were determined in plasma by performing an enzyme-
linked immunosorbent assay of samples drawn after hospital admission (
24 hours after stroke) from 57 patients with
ICH. The diagnosis of ICH was made on the basis of findings on computerized tomography (CT) scans. The volumes
of ICH and PHE were measured on baseline and follow-up CT scans at the same time that the patient’s neurological
status was assessed using the Canadian Stroke Scale and the Glasgow Coma Scale. Increased expression of MMP-9
was found among patients with ICH. In cases of deep ICH, MMP-9 was significantly associated with PHE volume
(r = 0.53; p = 0.01) and neurological worsening (237.4 compared with 111.3 ng/ml MMP-9; p = 0.04). A logistic re-
gression model focusing on the study of absolute PHE volume showed ICH volume as an independent predictor (odds
ratio [OR] 3.37; 95% confidence interval [CI] 1.1–10.3; p = 0.03). A second analysis of relative PHE volume (absolute
PHE volume/ICH volume) in patients with deep ICH demonstrated that the only factor related to it was MMP-9 con-
centration (OR 11.6; 95% CI 1.5–89.1; p = 0.018).
Conclusions. Expression of MMP-9 is raised after acute spontaneous ICH. Among patients with deep ICH this in-
crease is associated with PHE and the development of neurological worsening within the acute stage.

KEY WORDS • brain edema • intracerebral hemorrhage • matrix metalloproteinase •

perihematomal hypodensity • stroke
hemorrhage is a major cause of death.
I
NTRACEREBRAL
Authors of several studies have identified ICH volume
as a main factor related to morbidity and mortality dur-
ing the acute stage of ICH.10,12,22,37 In addition, the develop-
ment of a hypodense area surrounding the ICH (PHE), ac-
companied by an enlargement of the ICH, has been shown
to be responsible for neurological deterioration in some pa-
tients who have survived an early mass effect.25,41
Matrix metalloproteinases are a family of proteolytic en-
zymes involved in the reorganization of the extracellular
matrix, which play an important role in many physiological
processes.28 Matrix metalloproteinase–9 (gelatinase B) and
MMP-2 (gelatinase A) specifically degrade major compo-
nents of the basal lamina, leading to the disruption of the
blood–brain barrier.30,31 In recent years, MMP-9 has been re-
lated to different conditions, such as multiple sclerosis23,29
and cerebral ischemia,13,18 in which disruption of the blood–
brain barrier has been demonstrated. In contrast to the
growing evidence of the role of MMPs in acute cerebral
ischemia, their implication in ICH remains uncertain.
In the present exploratory study, we investigated the ex-
Abbreviations used in this paper: CI = confidence interval; CSS =
Canadian Stroke Scale; CT = computerized tomography; ELISA =
enzyme-linked immunosorbent assay; GCS = Glasgow Coma Scale;
ICH = intracerebral hemorrhage; MMP = matrix metalloproteinase;
MR = magnetic resonance; OR = odds ratio; PHE = perihematomal
edema; rPHE = relative PHE.
pression of MMP-9 in plasma after spontaneous ICH in hu-
mans and explored whether a relationship between MMP-9
and PHE exists. Furthermore, three MMP-9–related pro-
teins (TIMP-1, uPA, and MMP-3) were also studied to un-
derstand more clearly possible MMP-9 activation pathways
and the role of the MMP-9 inhibitor (TIMP-1) in this pro-
cess. Given that MMPs degrade components of the extra-
cellular matrix in the basal lamina, we hypothesized that an
imbalance between MMP-9 and its inhibitor in favor of
MMP-9, may relate to a larger PHE volume detected with-
in the first few days after symptom onset.
Clinical Material and Methods
Patient Population
During a period of 16 months, we prospectively studied
consecutively recruited patients with suspected spontane-
ous supratentorial ICH, which was diagnosed on the basis
of findings on CT scans obtained within the first 24 hours
after onset of stroke symptoms. Eighty-three patients were
initially enrolled in the study. A detailed history of vascular
risk factors, drug abuse, alcoholism, and concomitant med-
ication was obtained from each patient. Six patients (7.2%)
were excluded from the study because of the presence of
known acute or chronic infections, inflammatory or malig-
nant diseases, or immunosuppressive treatment. To identify

J. Neurosurg. / Volume 99 / July, 2003 65

 S. Abilleira, et al.

TABLE 1
Characteristics of patients with ICH
including risk factor profile and clinical variables*
Deep ICH Lobar ICH Total
Characteristic (38 patients) (19 patients) (57 patients)

male sex 24 (63.2%) 8 (42.1%) 32 (56.1%)

age in yrs 73 (59–77) 75 (63–83) 74 (61–79)
hypertension 25 (65.8%) 12 (63.2%) 37 (64.9%)
smoking 5 (13.2%) 2 (10.5%) 7 (12.3%)
chronic alcoholism 9 (23.7%) 4 (21.1%) 13 (22.8%)
previous stroke 12 (31.6%) 5 (26.3%) 17 (29.8%)
ischemic 6 (15.8%) 2 (10.5%) 8 (14%)
ICH 5 (13.2%) 3 (15.8%) 8 (14%)
unknown 1 (2.6%) 0 (0%) 1 (1.8%) FIG. 1. Bar graph demonstrating the plasma concentration of
diabetes 7 (18.4%) 2 (10.5%) 9 (15.8%) MMP-9 after spontaneous ICH. The dark gray zone indicates the
antiplatelet therapy 8 (21.1%) 4 (21.1%) 12 (21.1%) normal range for MMP-9 in healthy volunteers. Asterisks represent
GCS score extreme observations that are well separated from the remainder of
baseline 15 (13.75–15) 14 (10–15) 14 (13–15) the data.
follow up 15 (14–15) 15 (14.5–15) 15 (14–15)
CSS score
baseline 4.5 (3–6) 5 (3–7.5) 4.5 (3–6.5) nial CT scans were obtained according to the protocol fol-
follow up 5.5 (3–8) 6 (4–8) 5.75 (3–8)
neurological 6 (20.7%) 3 (23.1%) 9 (21.4%)
lowed by the neuroradiology department, with an image
worsening matrix of 340  340, and slices measuring 2.5 mm wide for
BP in mm Hg the posterior cranial fossa and 10 mm wide for the next
baseline 180 (149.5–190)/ 160 (140–190)/ 170 (146–190)/ slices (medium and anterior cranial fossae). The volume of
90 (80–110) 95 (80–110) 94.5 (80–110) ICH was measured on baseline and follow-up CT scans ac-
follow up 152.5 (132.5–170)/ 156 (140–167.5)/ 155 (140–170)/ cording to the formula A  B  C  0.5,14,20 where A and
80 (75.75–90.75) 80 (79–95) 80 (78–91)
temp in ˚C
B represent the largest perpendicular diameters through the
baseline 36.5 (36–36.8) 36.8 (36–37) 36.6 (36–36.95) hyperdense area on the CT scan and C represents the thick-
follow up 37.0 (36.6–37.35) 37 (36.65–37.3) 37.0 (36.6–37.3) ness of the ICH (the number of 10-mm slices containing
hemorrhage). The volume of PHE was measured on the fol-
* Data are expressed as number of patients (%) or as median value (inter-
quartile range). No difference between groups was considered statistically
low-up CT scan by subtracting the volume of the hyper-
significant. Abbreviations: BP = blood pressure; temp = temperature. dense region (ICH area) from the total lesion area, accord-
ing to the formula mentioned earlier. The rPHE volume was
defined as the PHE volume divided by the baseline ICH
potential sources of intracerebral bleeding, additional diag- volume (rPHE = PHE/baseline ICH). The ICH was catego-
nostic tools (MR imaging, MR angiography, conventional rized as deep when it was limited to the basal ganglia and/or
angiography, and coagulation tests) were performed when the thalamus, or lobar when it affected predominantly the
needed to rule out the presence of vascular malformations subcortical white matter of cerebral lobes.
or aneurysms (seven patients [8.4%]), tumors (one patient
[1.2%]), hemorrhagic infarctions (one patient [1.2%]), and Enzyme-Linked Immunosorbent Assays for MMP-9, uPA,
coagulopathies (no patient). We also excluded patients who MMP-3, and TIMP-1
underwent any surgical procedure (10 patients [12%]) or Venous blood samples were drawn from each patient at
had been affected by an intraventricular ICH (one patient the initial visit. Tubes coated with ethylenediamine tetra-
[1.2%]). Fifty-seven patients were thus included in the final acetic acid were used to collect the blood. Plasma was im-
analysis. Informed consent was obtained from all patients mediately separated by centrifugation at 3000 rpm for 15
or their relatives. minutes and stored at 80˚C until the analysis was com-
Clinical examination was performed at the time of hospi- pleted. The levels of MMP-9, uPA, MMP-3, and TIMP-1
tal admission (baseline visit
24 hours after stroke onset) were determined using a commercially available ELISA kit
and between the 3rd to the 6th day (follow-up visit); this according to the manufacturer’s instructions (for MMP-9,
was concurrent with the timing of CT examinations. Pa- MMP-3, and TIMP-1, we used a Biotrack kit from Amer-
tient’s scores on the GCS35 and CSS7,8 were recorded to as- sham Pharmacia, Buckinghamshire, UK; for uPA, we used
sess their levels of consciousness and neurological status, a No. 111120 uPA kit from Tintelize Biopool AB, Umea,
respectively, at each examination. Neurological worsening Sweden). Previously personnel in our laboratory deter-
was defined as a decrease in one or more points in the CSS mined the standard values for MMP-9, TIMP-1, MMP-
score between testing periods.4,9 Blood samples were ob- 3, and uPA in a group of healthy people. Standard values
tained and arterial blood pressure and temperature values (mean values  two standard deviations) were determined
were noted on admission and at the follow-up visit. to be the following: 41  55.7 ng/ml for MMP-9 (62 pa-
tients, 58% of whom were male with a mean age of 43
Protocol for CT Scanning
years; normal range
97 ng/ml), 625.4  152.1 ng/ml for
Two cranial CT scans were obtained in all patients who TIMP-1 (40 patients, 30% of whom were male with a mean
survived the first 3 days: one at the time of the initial visit age of 44 years; normal range 473.2–777.5 ng/ml), 2.46 
(baseline) and the other during the follow-up visit. All cra- 1.34 ng/ml for MMP-3 (38 patients, 31.6% of whom were

66 J. Neurosurg. / Volume 99 / July, 2003

Matrix metalloproteinase–9 after intracerebral hemorrhage

TABLE 2
Data obtained from baseline and follow-up CT scans*
Deep ICH Lobar ICH p Total
Factor (38 patients) (19 patients) Value (57 patients)

time from stroke onset to baseline CT scan (hrs:mins) 6:30 (2:30–10:38) 6:30 (5:23–10:04) NS 6:30 (2:45–9:53)
lt-sided ICH 23 (60.5%) 7 (36.8%) NS 30 (52.6%)
presence of early PHE† 17 (51.5%) 13 (86.7%) 0.02 30 (52.6%)
IVH/SAH contamination 17 (44.7%) 7 (36.8%) NS 24 (42.1%)
baseline ICH volume (cm3) 15.8 (6.1–39.6) 36.3 (16–87.4) NS 20.5 (8.8–54.3)
follow-up ICH volume (cm3) 11.1 (5.1–20.4) 30.1 (10–48.1) NS 13.6 (6.2–26.8)
PHE volume (cm3) 19.2 (5.8–50.6) 24.3 (15.1–44.8) NS 19.3 (9.4–46.7)
* Data are expressed as number of patients (%) or as median value (interquartile range). Abbreviations: IVH = intraventricular hem-
orrhage; NS = not significant; SAH = subarachnoid hemorrhage.
† Presence of PHE on the baseline CT scan.

male with a mean age of 44 years; normal range  6.58 ng/
ml), and 0.35  0.25 ng/ml for uPA (40 patients, 50%
of whom were male with a mean age of 44 years; normal
range  0.609 ng/ml).
Statistical Analyses
Statistical analyses were conducted using a commercial-
ly available software program (SPSS [version 10.0]; SPSS,
Inc., Chicago, IL). For parametric variables the mean val-
ues  standard deviations are given, whereas for nonpara-
metric variables median values and interquartile ranges
are expressed. Given the small patient population studied,
when subsets of deep and lobar ICH were analyzed sepa-
rately nonparametric tests were used, whereas the whole
sample was basically analyzed using parametric tests. The
statistical significance of intergroup differences was as-
sessed using the Pearson chi-square test or the Fisher ex-
act test for categorical variables, and by using the Student
t-test and analysis of variance for continuous variables. The
Mann–Whitney U-test and the Kruskall–Wallis test were
used to analyze nonparametric variables or when variables
were not normally distributed. To study correlations be-
tween continuous variables we used Pearson or Spearman
coefficients.
The median value was used to classify PHE volume and
rPHE volume in two groups. Sensitivity and specificity
were calculated to obtain a cutpoint value for continuous
variables to predict the PHE and rPHE volumes configuring
a receiver operating characteristics curve. Two logistic re-
gression analyses were performed to determine factors that
could be considered independent predictors for the PHE
and rPHE volumes in deep ICH by using the forward step-
wise method of the likelihood ratio test. A probability value
less than 0.05 was considered statistically significant.
1 and 2). The mean MMP-3 and uPA values of the series
were 3.09  2.2 ng/ml and 0.2  0.16 ng/ml, respectively,
and again no differences were found to be associated with
ICH location. Both MMP-3 and uPA values were within the
normal ranges specified at our laboratory.
Relationship Between MMP-9 Concentration and
PHE Volume
Among the 42 patients who survived the first 48 hours
and were examined at follow up with CT scanning, a mea-
surable PHE area was found in 38. Early incidences of mor-
tality were not related to MMP-9 concentration (167.93 
99.73 compared with 145.45  116.1 ng/ml; p = 0.5), but
appeared to be strongly associated with baseline ICH vol-
umes (87.16  37.38 compared with 21.72  23.25 ml;
p
0.001). The mean PHE volume was 30.7  33.2 ml,
and no differences were found when lobar and deep ICHs
were analyzed separately. A significant positive correlation
emerged between PHE volume and MMP-9 levels in pa-
tients with deep ICHs (r = 0.53; p = 0.01), but this could not
be demonstrated for those with lobar ICHs. A multivariate
analysis was used to study this relationship further. After a
multiple logistic regression model had been applied, only
baseline ICH volume remained an independent predictor of
PHE volume (OR = 3.37; 95% CI = 1.1–10.3; p = 0.03) (Ta-
ble 3). A cutpoint value of 14.3 ml for the baseline ICH vol-
ume had a positive predictive value of 91.4% to assess PHE
volume ( 19.1 ml,  19.1 ml). To study the rPHE volume

Results
Among the 57 patients analyzed, ICH was lobar in 19 pa-
tients (33.3%), whereas it was deeply situated in the other
38 cases (66.7%). Demographic data, risk factor profiles,
and clinical variables are presented in Table 1. Data from
baseline and follow-up CT scans are provided in Table 2.
The mean MMP-9 and TIMP-1 values in the present se-
ries were 151.3  111.4 ng/ml (normal range at our labora- FIG. 2. Bar graph showing the plasma concentration of TIMP-1
tory
97 ng/ml) and 1034  574 ng/ml (normal range at after spontaneous ICH. The dark gray zone indicates the normal
our laboratory 473.2–777.5 ng/ml), respectively. No differ- range for TIMP-1 in healthy volunteers. Asterisks represent extreme
ences were found to be associated with ICH location (Figs. observations that are well separated from the remainder of the data.

J. Neurosurg. / Volume 99 / July, 2003 67


TABLE 3
Factors associated with a PHE volume greater than 19.1 ml
in patients with deep ICH on the univariate analysis
and multiple logistic regression model
OR (95% CI)
Factor* Univariate Analysis Logistic Regression
baseline ICH volume 16.2 (2.4–107.2) 3.37 (1.1–10.3)
MMP-9 5.6 (0.8–38.5) NS
baseline CSS score 0.2 (0.04–0.9) NS
smoking 13.2 (0.6–273.5) NS
chronic alcoholism 23.7 (1.1–473.8) NS
* The median PHE volume and the baseline CSS score were used as the
cutpoint levels for these parameters. The MMP-9 and baseline ICH volume
cutpoint levels were obtained from the receiver operating characteristics
curves (MMP-9  111.3 ng/ml and baseline ICH volume  14.3 ml).
a second analysis was conducted among patients with deep
ICHs. The rPHE showed a significant positive correlation
to MMP-9 concentration (r = 0.54; p = 0.008). Moreover, a
higher rPHE was significantly associated with the absence
of concomitant antiplatelet therapy (1.9 [range 0–12.3]
compared with 0.5 [range 0–1.8]; p = 0.01), and showed a
trend toward an association with the absence of previous
stroke (p = 0.09). After univariate analysis, the MMP-9
concentration was the only factor associated with a rPHE
volume greater than 1.8 (OR 11.6; 95% CI 1.5–89.1; p =
0.018). A cutpoint value of 133.9 ng/ml for MMP-9 had a
positive predictive value of 73.5% to develop a PHE vol-
ume 1.8-fold greater than the baseline ICH volume.
The plasma concentration of MMP-9 was not related
to baseline or follow-up GCS and CSS scores, but in pa-
tients with deep ICH a statistically significant relationship
was found between higher MMP-9 levels and neurological
worsening (237.4 ng/ml [range 177.9–331.8 ng/ml] com-
pared with 111.3 ng/ml [range 28.1–192.3 ng/ml]; p = 0.04)
(Fig. 3).
Relationships Among MMP-9, uPA, MMP-3, and TIMP-1
The concentration of TIMP-1 was increased in both deep
and lobar ICH (Fig. 2), and there were no differences asso-
ciated with ICH location. We found differences between
deep and lobar ICH, however, when correlations between
TIMP-1 and MMP-9 were analyzed: a positive correlation
appeared between MMP-9 and TIMP-1 in those patients
with lobar ICHs (r = 0.57; p = 0.02). The concentration of
TIMP-1 was unrelated to the PHE volume in patients with
lobar or deep ICH.
The concentrations of uPA and MMP-3 were distinctive-
ly associated with the MMP-9 levels. Although uPA was
related to MMP-9 in patients with deep ICHs (r = 0.428;
p = 0.016), a trend in this association was found between
MMP-3 and MMP-9 in those patients with lobar ICH (r =
0.463; p = 0.08) (Table 4).
Discussion
The current study shows the following. 1) The plasma
concentration of MMP-9 is raised in patients with sponta-
neous supratentorial ICH when measured within the first 24
hours after onset of symptoms. 2) The concentrations of
MMP-9 positively correlate to PHE volumes in deep ICH
68
S. Abilleira, et al.
p Value
0.03
NS
NS
NS
NS
FIG. 3. Bar graph demonstrating the relationship between the
plasma concentration of MMP-9 and neurological worsening in pa-
tients with deep spontaneous ICH. *p
0.05.
and are the only factor associated with the rPHE volume. 3)
A different association between MMP-9 and its related pro-
teins depending on ICH topography.
To our knowledge, this is the first study in which an in-
creased plasma MMP-9 concentration has been demon-
strated after spontaneous supratentorial ICH in humans. Ex-
pression of MMPs, mainly MMP-9 and MMP-2, has been
widely investigated in animal models of focal cerebral isch-
emia,1,5,33 as well as in cerebral ischemia in humans.26,27
Nevertheless, knowledge of what role MMP plays after a
spontaneous ICH is scarce. Rosenberg, et al.,32 demonstrat-
ed increased levels of MMP-9 and MMP-2 in a rat mod-
el of ICH 24 hours after injection of bacterial collagenase
deep within the brain. The elevation of MMP-9 coincided
with the maximum edema surrounding the ICH. That study
revealed a significantly reduced edema volume in those ani-
mals treated with an MMP inhibitor.
In our study we found differences between deep and lo-
bar ICH: there was no association between MMP-9 and
PHE in lobar ICH and differences in the relationships be-
tween MMP-9 and its related proteins (MMP-3, uPA,
TIMP-1) regarding ICH location. These results should be
accepted with caution because they are likely to be influ-
enced by the small sample of this study, particularly the
subset of patients with lobar ICH. Nevertheless, alternative
explanations can be discussed. Castillo, et al.,3 found a dif-
ference in glutamate expression between cortical and deep
cerebral infarcts and argued for glutamate as a marker for
cerebral ischemia only in patients with cortical infarctions.
The presence of a measurement artifact when estimating
PHE volume in patients with lobar ICH might also explain
this difference. Lobar hemorrhages tended to be more irreg-
ularly shaped than deep ICH. Thus, when the formula A 
B  C  0.5 was applied to measure ICH volumes, as-
suming them to be elliptical, some cubic centimeters could
have been attributed to ICH volume to the detriment to PHE
volume.
Taken together, the results of the present study might
suggest a different temporal profile in the relationship be-
tween MMP-9 and PHE regarding localization. To support
this idea it is necessary to know what ELISA detects. The
ELISA for MMP-9 used in our experiment detects mostly
latent forms of MMP-9 and the inhibited complex (pro-
MMP-9 and pro-MMP-9-TIMP-1, respectively), whereas
the ELISA for TIMP-1 measures free TIMP-1 and TIMP-
1-pro-MMP-9 complexes. In patients with lobar ICH we
found a positive correlation between MMP-9 and TIMP-1
J. Neurosurg. / Volume 99 / July, 2003
Matrix metalloproteinase–9 after intracerebral hemorrhage

levels, meaning that what we detected were mainly inhibit- TABLE 4

ed complexes (pro-MMP-9-TIMP-1). Thus, among patients Correlation coefficients of baseline patient characteristics,
with lobar ICH, TIMP-1 inhibited larger amounts of pro- biochemical determinations, and CT results with MMP-9
MMP-9, leading to a lack of association, in this location, concentrations, depending on the location of the ICH
between MMP-9 and PHE. The absence of this positive
Variable Deep ICH Lobar ICH
correlation between TIMP-1 and MMP-9 in patients with
deep ICH, leading to greater amounts of noninhibited pro- MMP-3 0.004 0.463*
MMP-9, may explain why, in patients with deep ICH, uPA 0.428† 0.320
MMP-9 levels were associated with PHE. Supporting the TIMP-1 0.008 0.579†
idea of a different time course of expression of MMP-9 and baseline ICH volume 0.216 0.014
PHE volume 0.535† 0.212
TIMP-1 after lobar and deep ICH, we found that early PHE systolic BP 0.007 0.303
(seen on the baseline CT scan) occurred significantly more diastolic BP 0.210 0.040
frequently in patients with lobar ICH than in those with serum glucose 0.259 0.650‡
deep ICH, although there were no differences between body temperature 0.151 0.546†
groups according to the time from stroke onset to acquisi- neutrophils 0.196 0.546†
tion of the CT scan. Thus, we might argue that a distinct GCS score on admission 0.017 0.196
CSS score on admission 0.128 0.268
temporal profile regarding MMP-9 and TIMP-1 expression
exists depending on the location of the ICH. This might ex- * p
0.1.
plain the differences between the association between both † p
0.05.
‡ p
0.01.
enzymes and also differences between the association be-
tween MMP-9 and PHE.
A point of clinical interest in the current study is the find- both ICH and PHE volumes might be considered a weak-
ing of a significant association between higher MMP-9 ening factor of this study, primarily if we take into account
levels and neurological worsening in patients with deep that MR imaging has been clearly shown to be as reliable as
ICH. Perihematomal edema is a main cause of neurological CT scanning in assessing the neuroimaging differences be-
worsening that previously has been investigated by oth- tween ischemic and hemorrhagic stroke. In fact, compared
ers.25,41 To our knowledge, this is the first time that the with CT scans, diffusion-weighted and fluid-attenuated in-
plasma concentration of MMP-9 has been related to neu- version recovery sequences are the best MR imaging meth-
rological worsening in the setting of ICH, although this ods to quantify volumes, whereas conventional T2-weight-
relationship had already been established after human car- ed sequences produce better images of space-occupying
dioembolic stroke.26 The proinflammatory properties of edema and a midline shift.34 Although it seems clear that
MMP-9 have been widely accepted.6,17,21 In addition, in- MR imaging is as sensitive as CT scanning in the diagnos-
flammatory reaction occurs around the hematoma11,16,38,39 tic workup of a patient in a hyperacute condition, CT scan-
and exacerbates brain edema formation.24,36 ning still remains the selected tool in the assessment of ICH
In experimental studies MMP-9 activity in brain tissue and PHE volumes in very recent studies.2,15 On the other
has been examined using zymograms, whereas in the pres- hand, the follow-up CT scan was performed after a long pe-
ent study we have focused on the plasma concentration of riod of time. We selected such a long period of time to en-
MMP-9. The measurement of plasma levels of MMP-9 de- sure the appearance of a hypodense area around the ICH
termined by the ELISA used in this study mainly offers that would be suitable for measurement. The findings of
information about latent forms of MMP-9 and inhibited previous studies have indicated that brain edema increases
complexes. Previous studies published by our group26,27 and progressively during the first 24 hours. Brain water content
reports that have appeared in other cardiovascular fields19 remains elevated for several days and begins to resolve after
have shown that ELISA methods also provide useful infor- 5 days.40
mation. It is still a matter of controversy whether the origin
of the plasma MMP-9 concentration is endogenous, from Conclusions
astrocytes and microglia, or exogenous, from neutrophils.
Unfortunately, the findings of the present study cannot an- In this work we studied plasma concentrations of MMP-
swer this question, although we found an association be- 9 after acute spontaneous ICH in humans and demonstrat-
tween MMP-9 concentration and the number of neutrophils ed increased expression of this molecule when measured
in the presence of lobar ICH. within the first 24 hours after the onset of stroke symptoms.
Some limitations should be noted in the present study. In the presence of deep ICH raised levels of MMP-9 were
First is the small sample size that was studied, particularly associated with PHE and neurological worsening. This
the number of patients with lobar ICH. Ideally, a larger co- association should be further studied to understand more
hort including a similar number of patients with lobar and clearly the mechanisms leading to brain edema after ICH.
deep ICH should be enrolled. Second, a 24-hour time win-
dow could be considered an excessively long period of time Acknowledgments
to assess MMP-9 concentration. It would be of interest to
study MMP-9 concentration in a more homogeneous group We thank Miguel A. González-Sánchez and Manuel Quintana for
statistical analyses, and Anna Anglés for technical assistance when
of patients during a time period spanning 6 to 12 hours. Be- performing the MMP-9, MMP-3, uPA, and TIMP-1 ELISAs.
cause this is the first study performed in humans to address
the expression of this molecule after ICH, however, we References
think that it should be taken as an exploratory study. Third,
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Manuscript received October 28, 2002.
Accepted in final form March 28, 2003.
This study was supported by a grant from Spain’s Fondo de Inves-
tigación Sanitaria (FIS 01/1389) awarded by the Ministry of Health
and Welfare.
Address reprint requests to: José Álvarez-Sabín, M.D., Ph.D.,
Unitat Cerebrovascular (Servei de Neurologia), 6a planta, Hospital
General Vall d’Hebron, Passeig Vall d’Hebrón 119-129, 08035 Bar-
celona, Spain. email: alsa@hg.vhebron.es.
J. Neurosurg. / Volume 99 / July, 2003