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Table of Contents    
Year : 2013  |  Volume : 61  |  Issue : 6  |  Page : 606-609

Matrix metalloproteinases and their tissue inhibitors in serum and cerebrospinal fluid of patients with moderate and severe traumatic brain injury

1 Department of Neuroscience, College of Life Science, Hebei University, Hebei Province, China
2 Department of Neurosurgery, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
3 Department of Neurosurgery, Shanghai Pudong New area People's Hospital, 201299, Shanghai, China

Date of Submission02-Oct-2013
Date of Decision23-Nov-2013
Date of Acceptance09-Dec-2013
Date of Web Publication20-Jan-2014

Correspondence Address:
Zhenshan Wang
College of Life Science, Hebei University
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Source of Support: Supported by the Natural Science Foundation of Hebei Province (No. 2012201136) and Medical Science Special Foundation of Hebei University (No. 2012B2004), Conflict of Interest: Hebei postdoctoral fund (No. 111867).

DOI: 10.4103/0028-3886.125258

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 » Abstract 

Objective: In this study, we investigated matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinase (TIMPs) in cerebrospinal fluid (CSF) and plasma of traumatic brain injury (TBI) patients. Patients and Methods: A total of 30 patients with moderate and severe TBI and 15 age-matched controls were enrolled in this study. Plasma and CSF samples were collected within 24 h (as the initial value), at 72 and 120 h post injury. CSF and plasma MMP-9, MMP-2, TIMP-1 and TIMP-2 were estimated using ELISA. Different levels of these indexes were compared in the two groups and further investigated the correlation between each other. Results: There was a significant elevation in the levels of the initial MMP-9 in the CSF (P < 0.05), which lasted for 72 h post injury. TIMP-1 kept increasing within 120 h post injury and it was different compared with TIMP-1 at 24 and 72 h post injury. Plasma levels of MMP-9, MMP-2, TIMP-1 and TIMP-2 in TBI patients were also significantly different from those in controls. Furthermore the CSF MMP-9 in patients with severe TBI was higher than that in patients with moderate TBI. In addition, there was a positive relationship between the initial MMP-9 and TIMP-1 at 120 h post injury (r = 0.614, P < 0.01). Conclusion: MMPs and TIMPs are increased in both CSF and plasma of TBI patients. TIMP-1 has a positive correlation with MMP-9 and the initial MMP-9 is associated with the neurological outcomes.

Keywords: Cerebrospinal fluid, matrix metalloproteinase, tissue inhibitor of metalloproteinase, traumatic brain injury

How to cite this article:
Zheng K, Li C, Shan X, Liu H, Fan W, Wang Z, Zheng P. Matrix metalloproteinases and their tissue inhibitors in serum and cerebrospinal fluid of patients with moderate and severe traumatic brain injury. Neurol India 2013;61:606-9

How to cite this URL:
Zheng K, Li C, Shan X, Liu H, Fan W, Wang Z, Zheng P. Matrix metalloproteinases and their tissue inhibitors in serum and cerebrospinal fluid of patients with moderate and severe traumatic brain injury. Neurol India [serial online] 2013 [cited 2023 Jun 4];61:606-9. Available from:

 » Introduction Top

Traumatic brain injury (TBI) is a major cause of death and disability in Western countries [1] and also a major public health problem. [2] The scenario is same in China also. [3] The pathophysiological mechanisms implicated in the cellular and molecular change following TBI remains unclear. Reliable biomarkers for early prediction of prognosis and functional recovery are very few. [4],[5] Matrix metalloproteinases (MMPs) are a group of homologous enzyme activity dependent on Ca 2+ and Zn 2+ in the medium protease family and these participate in maintaining homeostasis of extracellular matrix (ECM) and are associated with the destruction of the blood-brain barrier, cerebral edema, inflammatory reactions and tissue necrosis. [6],[7],[8] There is almost no expression of MMP-9 in normal brain tissues similar to animals. [9],[10],[11] In animal experiments MMP-9 significantly increased within the first 3 h following brain injury reaching a peak at 24 h and lasted for nearly a week. [12] Compared with wild type mice, mice with knock-out of MMP-9 developed less autonomic dysfunction, less brain injury [13] and also less MMP-2 expression following TBI. [14] Elevated levels of cerebrospinal fluid (CSF) and blood MMP-9 were also found in TBI patients. Elevated levels of MMP-2 were only detected in plasma at 72 h post TBI, but not in the CSF. [15] In this study, we focused on the CSF and plasma levels of MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP-1) and TIMP-2 in patients with moderate and severe TBI. We also investigated the relationship between these indexes and neurological outcome.

 » Patients and Methods Top

The Hebei Medical University Human Research Review Committee approved the study. Informed consent was taken from the family members for inclusion in the study. Patients selected were patients with TBI within a 24 h window from insult to ventriculostomy, performed for diagnostic and therapeutic purposes. Thirty patients (21 males and 9 females, mean age of 48 ± 6 years) with a moderate or severe head TBI (glasgow coma scale [GCS] score of 12 or less at admission) and ventricular catheter were recruited in the study between January 2012 and October 2012. Patients with TBI with associated infection, peripheral bleeding disorder, tumor and other concomitant traumatic injuries were excluded. Patients were further grouped into the moderate (GCS >8) or severe (GCS <9) arm. 15 age and gender-matched (10 males and 5 females with mean age of 47 ± 7 years) subjects with acute headache, in whom diagnostic lumbar puncture was performed to exclude intracranial hemorrhage or inflammatory diseases were the controls. Control group had paired CSF and plasma collected at the time of lumbar puncture.

Human MMP-2, MMP-9, TIMP-1, TIMP-2 Quantikine® ELISA kits (Shanghai, China) were used to measure serum MMPs and TIMPs level. All patients with TBI had paired samples at all-time points and there were no missing data.

All patients underwent Karnofsky assessment at 6 months by an experienced neurosurgeon who was blinded to the laboratory data. A score of 90-100 was considered as good outcome; while, a score <90 was considered as poor outcome.

Statistical analyses were performed using the GraphPad Prism software package (GraphPad 5.0, San Diego, CA). Data are expressed as mean ± standard error of the mean. Two paired groups were compared with t-test and multiple groups were compared with one-way ANOVA. Furthermore, the relationship between the parameters was tested by Pearson analysis. The receiver operating characteristic (ROC) was used to assess the acute density of MMP-9 and MMP-2 for the assessment. Significance was set as a P < 0.05.

 » Results Top

CSF MMP-9, MMP-2, TIMP-1 and TIMP-2 levels were significantly elevated in TBI patients (measured within 24 h of trauma), compared with the control group (P < 0.05) [Table 1]. Blood MMP-9, MMP-2, TIMP-1, TIMP-2 levels in TBI patients within 24 h were also significantly different from those in controls (P < 0.05) [Table 2].
Table 1: CSF MMP-9, MMP-2, TIMP-1 and TIMP-2 levels in TBI patients and the control group

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Table 2: Plasma MMP-9, MMP-2, TIMP-1 and TIMP-2 levels in TBI patients and the control group

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The CSF MMP-9 level in patients with severe TBI was significantly higher than that in patients with moderate TBI (82.68 ± 17.22 vs. 42.42 ± 14.94). However, there were no significant differences in MMP-2, TIMP-1 and TIMP-2 between the two groups [Table 3].
Table 3: CSF MMP-9, MMP-2, TIMP-1 and TIMP-2 levels in moderate and severe TBI patients

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There was no significant difference in the serum levels of MMP-9, MMP-2, TIMP-1 and TIMP-2 between severe TBI and moderate TBI, MMP-9 (75.86 ± 41.50 vs. 62.00 ± 34.86), MMP-2 (13.53 ± 17.34 vs. 13.10 ± 8.43), TIMP-1 (138.61 ± 44.726 vs. 129.10 ± 37.27) and TIMP-2 (27.37, ±6.51 vs. 24.19 ± 20.63), respectively.

The CSF MMP-9 level reached the peak within 24 h post injury, which lasted at least 72 h and there was no statistical difference between the 24-h point (71.34 ± 13.93) and 72-h point (49.63 ± 8.93), but both of them were different from the 120-h point (26.15 ± 4.89). The peak of TIMP-1 occurred at 120-h point (162.24 ± 17.15) and it was much higher than that at 72-h point (142.91 ± 11.17) and 24-h point (142.78 ± 16.47) [Figure 1]. However, CSF levels of MMP-2 and TIMP-2 did not demonstrate any significant change within 120 h post injury in patients with TBI. Similarly, the blood levels of each factor had no significant change over time.
Figure 1: The matrix metalloproteinase-9 reached the peak at 24 h post injury and followed by a downward trend within 120 h after the brain injury; in contrast, tissue inhibitor of metalloproteinase-1 kept increasing within 120 h following the injury

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In TBI patients, there was positive correlation between CSF MMP-9 (24 h) and CSF TIMP-1 (120 h) (r = 0.614, P < 0.01), [Figure 2]. However, there were no other correlations between these parameters at other time points. Positive correlation between MMP-2 and TIMP-2 was found at each point of measurement [Table 4].
Figure 2: The plot figure of initial matrix metalloproteinase (MMP9) and tissue inhibitor of metalloproteinase (TIMP1) at 120 h post injury. There was a positive correlation between the initial MMP9 and TIMP1 on the 5th day post brain injury (r = 0.612, P < 0.05)

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Table 4: A positive correlation between MMP-2 and TIMP-2

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The average score in severe TBI group was 56.38 ± 15.64, while that in moderate group was 78.91 ± 4.89. ROC curve, initial CSF MMP-9 and MMP-2 were correlate with the long-term quality of life assessment. Status of both MMPs predicted the neurological outcome [Figure 3]. The MMP9 had a significant predictive value for neurological outcome in TBI patients (area under the curve: 0.819 vs. 0.353). On the ROC curve for MMP-9, the corresponding specificity at 75.11 ng/mL was 100% and the sensitivity was 64.7% [Figure 3].
Figure 3: Comparison of receiver operating characteristic curves. Green curve: Probability of neurological outcome on matrix metalloproteinase (MMP2) status; Blue curve: Probability of neurological outcome on MMP9 status

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 » Discussion Top

Several MMPs are constitutively expressed, including MMP-2, which is normally found in brain and CSF. During inflammation and other acute brain injuries MMPs are expressed. [16] In addition, MMP-9 contains a nuclear factor-kappaB site, [17] which gets activation during the inflammatory process. In acute stroke patients, MMP-9 levels increase in CSF and blood and also in the blood of patients with intracranial hemorrhage. [18]

In our study, there was an increased CSF level of TIMP-1 and TIMP-2 in TBI patients and further there was a positive correlation between the initial MMP-9 and TIMP-1 at 120 h post injury. Other studies show the TIMP-1 can specifically inhibit the MMP-9 and TIMP-2 can selectively inhibit the MMP-2. [19],[20] The TIMP has a function of negative control in the metabolism of ECM, which can inhibit the activation and function of MMPs and further affect the protein proteolysis during the injury. [21],[22] Under pathological condition, the equilibrium of MMPs and TIMPs is perturbed, then it will cause a series of pathological changes implicated in several neurological diseases. [23],[24]

In this study, there was an increasing trend in CSF TIMP-1 over a period of 120 h post injury. Both CSF MMP-2 and TIMP-2 did not show a consistent change during the 120 h post injury, however, certain correlation was maintained between them. We speculate that the changes in TIMPs resulted from the activation of MMPs and further the endogenous TIMPs might be neuroprotective. This is further supported by the decreasing trend of MMP-9 with the progressive increase in TIMP-1 and a positive correlation between the initial MMP-9 and later TIMP-1 post injury. This provides a theoretical basis for exogenous TIMPs in TBI. In this study, admission CSF MMP-9 was a predictor of neurological outcome. This further strengthens the interest of targeting MMPs in TBI.

There are some limitations to our study. The sample size was small and the statistical power may not be robust. The study focused on the MMP-9 and MMP-2, other MMPs might be involved in the neuronal injury. In this study, Karnofsky performance scale was used to assess the outcome. However, this scale is much more focused on the quality of life. It does not specifically assess the sensori-motor and cognitive dysfunction that occurs in patients with TBI. In our future study, we would like to enroll more patients to validate the observations made in this study and further look at other MMPs and use a battery of neurobehavioral and neurocognitive tests to explore the exact correlation between MMPs and neurological outcome in patients with TBI.

 » References Top

1.Bruns J Jr, Hauser WA. The epidemiology of traumatic brain injury: A review. Epilepsia 2003;44:2-10.  Back to cited text no. 1
2.Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: A brief overview. J Head Trauma Rehabil 2006;21:375-8.  Back to cited text no. 2
3.Jiang JY. Collaborators CHTS. Head trauma in China. Injury 2012; In press.  Back to cited text no. 3
4.Begaz T, Kyriacou DN, Segal J, Bazarian JJ. Serum biochemical markers for post-concussion syndrome in patients with mild traumatic brain injury. J Neurotrauma 2006;23:1201-10.  Back to cited text no. 4
5.Kochanek PM, Berger RP, Bayir H, Wagner AK, Jenkins LW, Clark RS. Biomarkers of primary and evolving damage in traumatic and ischemic brain injury: Diagnosis, prognosis, probing mechanisms, and therapeutic decision making. Curr Opin Crit Care 2008;14:135-41.  Back to cited text no. 5
6.Azeh I, Mäder M, Smirnov A, Beuche W, Nau R, Weber F. Experimental pneumococcal meningitis in rabbits: The increase of matrix metalloproteinase-9 in cerebrospinal fluid correlates with leucocyte invasion. Neurosci Lett 1998;256:127-30.  Back to cited text no. 6
7.Khrestchatisky M, Jourquin J, Ogier C, Charton G, Bernard A, Tremblay E, et al. Matrix metalloproteinases and their inhibitors, modulators of neuro-immune interactions and of pathophysiological processes in the nervous system. J Soc Biol 2003;197:133-44.  Back to cited text no. 7
8.Kanoh Y, Ohara T, Kanoh M, Akahoshi T. Serum matrix metalloproteinase-2 levels indicate blood-CSF barrier damage in patients with infectious meningitis. Inflammation 2008;31:99-104.  Back to cited text no. 8
9.Rosenberg GA, Navratil M, Barone F, Feuerstein G. Proteolytic cascade enzymes increase in focal cerebral ischemia in rat. J Cereb Blood Flow Metab 1996;16:360-6.  Back to cited text no. 9
10.Gasche Y, Fujimura M, Morita-Fujimura Y, Copin JC, Kawase M, Massengale J, et al. Early appearance of activated matrix metalloproteinase-9 after focal cerebral ischemia in mice: A possible role in blood-brain barrier dysfunction. J Cereb Blood Flow Metab 1999;19:1020-8.  Back to cited text no. 10
11.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;19:624-33.  Back to cited text no. 11
12.Lin Y, Pan Y, Wang M, Huang X, Yin Y, Wang Y, et al. Blood-brain barrier permeability is positively correlated with cerebral microvascular perfusion in the early fluid percussion-injured brain of the rat. Lab Invest 2012;92:1623-34.  Back to cited text no. 12
13.Wang X, Jung J, Asahi M, Chwang W, Russo L, Moskowitz MA, et al. Effects of matrix metalloproteinase-9 gene knock-out on morphological and motor outcomes after traumatic brain injury. J Neurosci 2000;20:7037-42.  Back to cited text no. 13
14.Wang X, Mori T, Jung JC, Fini ME, Lo EH. Secretion of matrix metalloproteinase-2 and-9 after mechanical trauma injury in rat cortical cultures and involvement of MAP kinase. J Neurotrauma 2002;19:615-25.  Back to cited text no. 14
15.Grossetete M, Phelps J, Arko L, Yonas H, Rosenberg GA. Elevation of matrix metalloproteinases 3 and 9 in cerebrospinal fluid and blood in patients with severe traumatic brain injury. Neurosurgery 2009;65:702-8.  Back to cited text no. 15
16.Johanson M, Zhao XR, Huynh-Ba G, Villar CC. Matrix metalloproteinases, tissue inhibitors of matrix metalloproteinases, and inflammation in cyclosporine A-induced gingival enlargement: A pilot in vitro study using a three-dimensional model of the human oral mucosa. J Periodontol 2013;84:634-40.  Back to cited text no. 16
17.Wang JJ, Huan SK, Hsieh KH, Chou HC, Hsiao G, Jayakumar T, et al. Inhibitory effect of midazolam on MMP-9, MMP-1 and MMP-13 expression in PMA-stimulated human chondrocytes via recovery of NF-κB signaling. Arch Med Sci 2013;9:332-9.  Back to cited text no. 17
18.Kavalci C, Genchallac H, Durukan P, Cevik Y. Value of biomarker-based diagnostic test in differential diagnosis of hemorrhagic-ischemic stroke. Bratisl Lek Listy 2011;112:398-401.  Back to cited text no. 18
19.Niebroj-Dobosz I, Janik P, Soko³owska B, Kwiecinski H. Matrix metalloproteinases and their tissue inhibitors in serum and cerebrospinal fluid of patients with amyotrophic lateral sclerosis. Eur J Neurol 2010;17:226-31.  Back to cited text no. 19
20.Ahmed SH, Clark LL, Pennington WR, Webb CS, Bonnema DD, Leonardi AH, et al. Matrix metalloproteinases/tissue inhibitors of metalloproteinases: Relationship between changes in proteolytic determinants of matrix composition and structural, functional, and clinical manifestations of hypertensive heart disease. Circulation 2006;113:2089-96.  Back to cited text no. 20
21.Visse R, Nagase H. Matrix metalloproteinases and tissue inhibitors of metalloproteinases: Structure, function, and biochemistry. Circ Res 2003;92:827-39.  Back to cited text no. 21
22.Lorenzl S, Albers DS, LeWitt PA, Chirichigno JW, Hilgenberg SL, Cudkowicz ME, et al. Tissue inhibitors of matrix metalloproteinases are elevated in cerebrospinal fluid of neurodegenerative diseases. J Neurol Sci 2003;207:71-6.  Back to cited text no. 22
23.Renaud S, Leppert D. Matrix metalloproteinases in neuromuscular disease. Muscle Nerve 2007;36:1-13.  Back to cited text no. 23
24.Rosenberg GA. Matrix metalloproteinases and their multiple roles in neurodegenerative diseases. Lancet Neurol 2009;8:205-16.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]

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