Author: Prof. Zofia Kazibutowska-Zarańska [ dead V 2018 ], Slawomir Graff, M.D.
THE FIBRINOLYSIS INHIBITORS IN THROMBOTIC STROKE :
„THE FIBRINOLYSIS INHIBITORS IN ISCHEMIC THROMBOTIC STROKE AND TIA PATIENTS – CLINICAL ANALYSIS OF 30 CASES”
KEY WORDS : thrombosis, fibrinolysis, α2-antiplasmin, plasminogen activator inhibitor typ 1 ( PAI-1 ).
ABSTRACT:
Background and purpose: In the pathophysiology of thrombotic diseases, among the numerous group of activators, inhibitors and modulators of coagulological processes, a great significance have fibrinolysis inhibitors:α2-antiplasmin ( A2APL ) and plasminogen activator inhibitor type 1 ( PAI-1 ). There were estimated PAI-1 activity and A2APL concentrations in acute phase ischemic thrombotic stroke ( TS ) patients plasma, however this results were compared to same other coagulological and morphological parameters for define their role in the pathogenesis of this disease.
Methods : Evaluation of PAI activity and A2APL concentration in plasma by chromoaffinity methods inclusively with analyses of fibrinogen value, hemostasis times indicators and morphological blood analyses in 1st, 3rd and 14th day of TS. There were also simultaneously observed, using a scale, clinical status and head computed tomography ( CT ) performed.
Results: There were registered elevated values of A2APL concentrations in according to thrombocytosis in third day of TS in men ( p< 0.023 ) and in dependence of higher grade of neurological deficit ( p< 0.032 ). In 14th day of TS onset a decrease of A2APL concentrations mainly in men were noted ( p< 0.033 ). In the 1st , 3rd and 14th days of TS statistically significantly elevation of PAI activity was shown such as increase of mean PAI activity according to elevated prothrombin contents and abbreviated aptt in 14th day of TS onset were observed.
Conclusions: The fibrinolysis inhibitors are playing an important role in TS process. The meaning of each one of their is different. The increase of PAI activity shows to be a risk factor for TS, whereas A2APL concentration fluctuations remain not so clear in the pathogenesis of ischemic thrombotic stroke.
Atherosclerosis determines the most often patogenesis of the contemporary civilization diseases incuding stroke and it may has a course associate with coagulological disturbances [ 1, 2, 3 ].
In the present study the attention was concentrate in a problem of hypercoagulability, which in some cases, e.g. in patients with hiperfibrinogenemia, can be very important cause for stroke fall [ 4, 5, 6, 7 ]. There would be suggest that the ischemic stroke following thrombosis could be a result of increased blood coagulability as a reason of elevated fibrinolysis inhibitors activity [ 8, 9, 10, 11, 12, 13 ]. A purpose of this study is to determine part of this phenomenon.
The fibrinolysis is a complicated process conditioned by numerous factors and can be inhibited in various stages.
Excessive fibrinolysis inhibitors activity may has a character of stable inherited failure ( Thrombophilia ), which occasionally increases following clinical manifestation or can induce Hypercoagulabilitas, as an aquired dysfunction causing influence of pathogens-inductors, such as e.g. Infectio or another kind of Distress [ 22, 23 ].
Materials :
The analysed material includs selected subgroup from patients admitted into Neurological Dept. of Upper Silesian Medical Center in Katowice in the time period of three years. The cause of admission were acute focal brain ischemia.
There were included to analysis 30 patients aged 55-79 years ( mean 66.4 y. ); 24 male aged 55-79 years ( mean 65.8 y. ) and 6 female aged 57-74 years ( mean 68.7 y. ) were among patients.
Inclusion criterions were :
• clinical signs of acute, focal, brain ischaemia ;
• time from stroke onset less then 48 hours;
• head CT scans excluding intracranial haemorrhage;
• probable thrombotic stroke mechanism.
Exclusion criterions were :
• admission into neurological department more then 48 hours after stroke onset;
• intracranial haemorrhage in CT;
• presence of heart defect, atrial fibrillation or insufficient circulation;
• oncological malignant processes in anamnesis;
• liver or kidney insufficiency.
As a thrombotic stroke was acknowledged an acute focal brain ischemia onset during sleep or direct after awake, when the neurological signs were appear increasing gradually in patient without heart arrythmia, without organic acquired heart disease, without brain haemorrhage in CT.
Among patients there were 28 persons with ischemia in a. carotis interna ( ICA ) vascularisation territory and 2 persons with ischemia in vertebro-basilar aerial and in CT imaging confirmed .
According to clinical course there were :
Transient Ischemic Attack ( TIA ) – 2 cases,
Reversible Ischemic Neurologic Deficit ; Partial RIND ( RIND and PRIND )– 11 cases,
Completed Stroke ( CS ) – 11 cases,
Progressive Stroke ( PS ) – 6 cases.
The fact that TIA patients were inculing into stroke group patients follows opinion of Jędrzejowska [ 25 ]. This author mentioned that neither etiopathogenic criterions, clinical signs, nor usually early neuroradiological view and the therapeutical grounds do not differentied TIA and stroke.
In patients with stroke or TIA there were ascertained :
• Hypertonia arterialis in 15 patients,
• Status post infarctum myocardii vel Morbus ischaemicus cordis seu Atherosclerosis generalisata in 11 patients,
• Diabetes mellitus in 7 patients,
• Morbus ulcerosus ventriculi seu/et duodenii in 4 patients,
• Infectio ( manifest inflammatory state ) in 2 patients.
Present Medical Center has taken a part in International Stroke Trial ( IST ) and his patients have had randomized choosen art of therapy: 9 patients received Acidum Acetylosalicylicum, 8 patients Heparinum with Acidum Acetylosalicylicum, 6 patients only Heparinum and 7 neither Heparinum, nor Acidum Acetylosalicylicum [ 26 ]. At the same time the greater part of patients received hemodilution by Dextranum 40000 and one of the medicines: Nicergoline, Pentoxifiline, Naftydrofuryl, Vinpocetine.
Selected control group consisted 20 healthy subjects within age matched ( mean age 64 y.; 54-72 y.; 10 male aged 58-72 y., mean 64.8 y. and 10 female aged 54-70 y., mean 63.1 y. ) without exclusion criterions and those which expressed informed consent.
Methods :
In the present study there were performed simultanously determination fibrinolysis inhibitors values together with another selected coagulological indicators, blood cell count and compare with qualitative and quantitative clinical status.
In all the patients there were performed :
1. Routine neurological investigation in the 1st ,3rd and 14th day from stroke onset. In neurological estimation a 50-grade neurological deficit scale were used, which in this Neurological Dept. since 1990 year is known and was used [ 27 ].
2. Routine phisical investigation with blood pressure measurement ( 1st, 3rd ,14th day of stroke onset ) and ECG at admission.
3. CT in 1st and between 10-14th day from stroke onset.
4. Blood testing ( 1st, 3rd and 14th day from stroke onset)
• Coagulological
Activity and concentration of fibrinolysis inhibitors ( PAI-1, A2APL ) by photometric kinetic method. In order to test fibrinolysis inhibitors levels there were taken, always at the same time, about 8 a.m., into plastic tubes 4.5 ml venous blood ( there is periodic circadian alteration of fibrinolytic system activity ) [ 28, 29, 30 ]. Using Behring Diagnostika reagents in Behring Chromo Time System ( a 4-channel photometer coupled to hardware: Apple GS II central unit, Seikosha SP 2400 printer ) measurements were performed at the value 405 nm light of mercuric lamp for the 36.8-37.2°C temerature interval. Normal concentration of A2APL in this method amounts 80-120%, and PAI activity: 0 – 3.5 U/ml [ 31 ]. The contents of each single cuvette for fibrinolysis inhibitors tests were divided to two parts and estimated separatly.
Fibrinogen contents in coagulometer Fibrintimer 2 Behring – turbidimetric method ( normal range 1.8-3.5 g/l );
Prothrombin time ( norm 12-18 s) and its contents ( norm 80-120%);
Thrombin time ( norm 14-21 s);
Kaolin-kephalin time ( norm 22-35 s) { aptt }
• morphological : hematocrit, hemoglobin, erythrocyties, leucocyties, thrombocyties counts in automatic analysier „Celltrag 11“ Nova.
Statistical methods
In the statistical analysis t- Student’s test for non-bind variables was used. For the estimation fibrinolysis inhibitors values compared with other parameters the regression and correlation analysis in line model χ2 Pearson was performed. ANOVA range Kruskal-Wallis test and variance analysis for comparison dependence of fibrinolysis inhibitors with clinical course took advantage. Statistical significant values were acknowledged there, that in essential tests performed p values no more then 0.05.
Results :
Fibrinolysis inhibitors
There was revealed statistically significant interrelationship increase A2APL concentrations with elevation thrombocytosis in 3rd day from TS onset ( p< 0.04 ), particularly in men ( p< 0.023 ).
There were acknowledged significant correlation between grade of neurological deficit at admission and A2APL concentration in third day of stroke ( p< 0.05 – p < 0.032 according to statistical method ) in comparison to patients with lower initial neurological deficit.
Moreover there was ascertained statistically significant decrease A2APL concentration in 14th day from TS onset both sex ( p< 0.03 ) but especially in men ( p< 0.0033 ) in comparison to control group.
In patients with A2APL concentration varied off norm ( increased or decreased ) in 14th day TS there was observed worse clinical course ( p< 0.04 ) in relation to first day TS in comparison with patients having normal A2APL concentrations.
There was shown statistically significant elevation PAI-1 activity in both sex patients in 3rd day TS ( p< 0.0006 ) and in men in 1st day TS ( p<0.0076 ), 3rd day ( p< 0.00011 ) and 14th day from TS onset ( p< 0.006 ) in relation to control group.
There was revealed statistically significant interrelationship elevated PAI activity in 14th day from TS onset together with decreased prothrombin contents ( in both sex p< 0.048; in men p<0.05 ), likewise interrelationship elevated PAI activity with prolonged aptt ( in both sex p< 0.025 ; in men p< 0.019 ).
Furthermore in 14th day from stroke onset appears a negative correlation between elevated PAI activity and lowered count of erythrocytes.
Thrombocytosis
There was shown statistically significant increase count of platelets in 14th day from TS onset in both sex patients ( p< 0.00025 ) and in men ( p< 0.0026 ) in relation to the control group.
Discussion :
There was observed different proprietress in both analysed fibrinolysis inhibitors ( A2APL, PAI-1 ) in acute period TS patients. A similar relations in mice model of disease have present Nagai et al., 1999 [ 32 ] and Dewerchin et al., 2001 [ 19 ] postulating more important role A2APL then PAI in TS and conclude to point blocking of its action in brain infarct therapy. Our study has shown, that in the worse neurological state patients ( 1st day TS ) there was often observed elevated A2APL concentration in 3rd day TS.
The elevation A2APL concentration in 3rd day TS has positive correlated, mainly in men, with thrombocytosis in the same time, what is of course essential thrombosis risk factor [ 2 ]. The thrombocytosis in present study was observed also in both sex and in men in 14th day of TS onset. A profound analysis, here in part observed, coagulopathic dependences in stroke have elaborate Hart and Kanter, 1990 [ 33 ].
In patients demonstrating a worse evolution of neurological status between 1st and 14th day of TS there was observed interrelationship failed A2APL concentrations in 14th day TS i.e. so elevated as lowered ( over the norm range ), what indicate additionally an unprofitable influance of quantitative disturbations this fibrinolysis inhibitor on the neurological state acute TS patients.
Generelly there was shown in 14th day from TS onset, especially in men, a tendency to decrease A2APL concentration. This fact may explain an exhaustion of its contents after TS with accompanying failured fibrinolysis mechanism. A treatment beeing used, shows to have desirable influence assisting fibrinolysis, on the other hand it requires further experiments e.g. farmacodynamical kinds.
Increased PAI activity in 3rd day of TS in both sex observed, in men has been present in 1st, 3rd and 14th day from TS onset, what confirms pathophysiological significance excess the fibrinolysis inhibitor for TS, accepted by a lot of authors as a thromogenesis risk factor too [ 2, 11, 34, 35 ]. A comparable technics in examinations PAI-1 activity using chromogenic reagents, as present, have written already in 1990 Han, Chen and Mao [ 36, 37 ]. They have observed increased PAI-1 activity in TS patients after acute phase. Zunker et al., 1999 have also noted statistacally signifacant elevation PAI-1 activity in ischemic stroke [ 12 ]. In the patients with probable thrombotic stroke cause in 14th day of stroke we observed still considerably increased activity of PAI in blood, despite A2APL, kaolin-kephalin time and count of erythrocytes at managed treatment – decreased.
Commonly the analysed indicators times have demonstrate prolonged values in all the time TS observations ( 1st, 3rd, 14th day TS ) what followed in agreement to intention used anticoagulant and antiplatellet treatment, because after heparin medication there is aptt prolongation and prothrombin lowered content expect. Tohgi et al., 1993 have communicate about PAI level lowering following acetylosalicylic acid medication [ 26 ].
Statistically significant hiperfibrinogenemia noted in 1st, 3rd and 14th day from TS onset in both sex and in men was a distinct confirmation earlier well-known results of numerous studies [ 38, 39 ]. Similar observations have had authors of [ 40 ].
ACKNOWLEDGMENTS AND FUNDING NOTE
The study was partial funding by support of Silesian Medical Academy in the period 1992-1993 (grant for measuring unit : Behring Chromo Time System).
Other financial support was given for reagents to study by concern „Centrostal” (courtesy of Mr. Maroń).
ATTENTION:
This research work establish a part of doctoral thesis of Sławomir Graff in Silesian Medical Academy in Katowice. Title of doctor’s work : „ The selected fibrinolysis markers in ischemic stroke patients ” – polish title :
„Wybrane wskaźniki fibrynolizy u chorych z udarem niedokrwiennym mózgu”.
However results of the study with material from years 1993-1996 only partial are published in that doctoral thesis .
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