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CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
From the Emergency Service Hospital Virgen de la
Arrixaca; the Neurology Division and the Hematology and Medical
Oncology Service, Hospital General Universitario, Murcia, Spain.
Intracranial hemorrhage is the third most frequent cause of
cerebrovascular disease, but few genetic risk factors have been associated with its development. Recently, it has been reported that
some polymorphisms that affect clotting factors increase the risk for
thrombosis. However, reports have analyzed the effect of polymorphisms
influencing the hemostatic state in bleeding disorders insufficiently.
A case-control study was conducted of 201 patients with spontaneous
intracranial hemorrhage and 201 control subjects matched for age, race,
sex, and selected risk factors (hypertension, smoking, and alcohol
consumption). Genomic polymerase chain reaction was used to analyze the
prevalence of 4 polymorphisms: factor V Leiden, prothrombin 20210A,
factor VII Exquisitely regulated hemostatic mechanisms have
evolved within the animal kingdom to protect against the ever-present
danger of fatal hemorrhage. Platelets and coagulation factors interact to generate the protective hemostatic plug that prevents blood loss at
sites of vascular injury. However, structural anomalies or changes in
the levels of different elements of the hemostatic system can result in
disturbances that may cause bleeding or thrombotic disorders.
Because thromboembolic disease is the most common cause of death in
developed countries,1 attention during the last 30 years
has been focused primarily on identifying molecular changes that play
important roles in the predisposition to persistent hypercoagulable
states. Initially, it was shown that an increased risk for venous
thrombosis is associated with a rare deficiency of anticoagulant
proteins (antithrombin, protein C, or protein S).2,3
Recently, 2 common genetic risk factors for venous thrombosis have been
identified By contrast, most studies analyzing the role of hemostatic alterations
in bleeding disorders have been focused on rare deficiencies of
different elements of the hemostatic system: platelet glycoproteins or
coagulation factors. Surprisingly, few studies have analyzed prothrombotic mutations in bleeding disorders, especially common polymorphisms, with functional consequences in the coagulation response.
Intracranial hemorrhage is the third most frequent cause of
cerebrovascular disorder; it accounts for 12% of all stroke
events.8 However, it is remarkable that only occasional
brief reports, mainly in newborns, analyzed the role of coagulation
factor disorders in the pathogenesis of cerebral hemorrhage. Of note is
the reported relevance of the factor XIII (FXIII) V34L polymorphism
found in a small series of 62 patients with primary intracranial
hemorrhage.9
The aim of the present study is to characterize genetic
alterations of the hemostatic system that might promote or protect against spontaneous bleeding in the brain. We analyzed the prevalence of 4 polymorphisms that affect clotting factors with relevant effect in
the levels or function of the encoded proteins that could therefore
determine procoagulant or prohemorrhagic states: FV Leiden, prothrombin
20210A/G, deletion/insertion (Del/Ins) of 10 nucleotides in the
promoter ( Selection of patients and control subjects
During the same period of time, we selected 201 control subjects by
reviewing the charts of a population of patients admitted to the
hospital who had no history of vascular, thromboembolic, or hemorrhagic
disease and who were not undergoing antithrombotic therapy. These
control subjects were chosen based on age, race, sex, and selected risk
factors for primary intracranial hemorrhage (smoking history, blood
pressure, and alcohol consumption) to match those of the respective
patient. Finally, we analyzed the frequency of the studied
polymorphisms in the general population from our region in 490 additional healthy white subjects, mainly blood donors (Table 1).
Patients, controls, and family members of those patients with low
levels of consciousness at presentation were fully informed of the aim
of this study. All subjects investigated gave their informed consent to
enter the study, which had been approved by the local ethics committee
and was performed in accordance with the tenets of the Declaration of
Helsinki, as amended in Venice in 1983.
Blood collection and DNA isolation
DNA studies Genotyping of FV Leiden, prothrombin 20210A/G, the 323
decanucleotide Del/Ins polymorphism of the FVII gene, and
FXIII V34L was performed by genomic polymerase chain reaction
amplification as described.4,5,7,10
Statistical analysis Data for continuous variables were expressed as mean ± SD. Two-tailed Student t test was used to compare continuous variables. Discrete variables were analyzed by the 2
test. P < .05 was considered to indicate statistical
significance. The strength of the association of the polymorphisms with
the occurrence of hemorrhage was estimated by calculation of the odds ratio (OR) with the EpiInfo software and the Cornfield method for the
calculation of 95% confidence intervals (CI).
Characteristics of the study population We assumed that a single genetic polymorphism by itself was unlikely to be responsible for the development of thrombus or hemorrhage but that it could influence disease risk in association with other factors. Therefore, the selection of patients and controls presented 2 special features to avoid the interference of other factors and to determine the role of polymorphisms that predisposed to or protected against disease. First, patients at high risk for intracranial hemorrhage, such as those with a personal history of acquired or congenital bleeding disorders or primary or secondary brain tumors, as well as patients undergoing antithrombotic therapy, were excluded. Second, to avoid the overrepresentation of classic hemorrhagic risk factors among patients, their respective controls were selected to match for age, race, sex, and selected risk factors for spontaneous intracranial hemorrhage (smoking history, blood pressure, and alcohol consumption). The general characteristics of patients and control subjects are shown in Table 1. According to this inclusion design, no significant differences were found in age, sex, and risk factor prevalence among patients and controls. Remarkably, we did not detect significant differences in coagulation tests or in number of platelets between patients and controls (Table 1).Our study did not include patients who died during transport to the hospital or at home; therefore, we cannot completely exclude an effect of survival bias. Table 1 shows the survival percentage 30 days after admission to the hospital; it does not differ from that of previous reports.8 Based on the type of intracranial hemorrhage and the risk factors associated with it, our data fit properly with those of previous reports of large numbers of patients.8 Sixty patients had subarachnoid hemorrhage (SAH), and most (70%) of them also had aneurysms. Primary intracerebral hemorrhage (PIH) was diagnosed in 141 of 201 patients. As expected, hypertension was the most prevalent risk factor in patients with PIH (Table 1). Prevalence of the FV Leiden, prothrombin 20210A/G, FVII-323 Del/Ins, and FXIII V34L polymorphisms in the case-control study Genotypic and allelic frequencies for the analyzed polymorphisms in the case-control study are shown in Table 2. The frequencies of these polymorphisms in the control group were similar to those identified in the general population of our region and did not differ from those previously reported in other Mediterranean countries.7,10-12 However, the frequency of FV Leiden, prothrombin 20210A/G, and FVII323
Del/Ins in patients with intracranial hemorrhage differed in patients
and controls. The mutated 20210A allele of the prothrombin gene was
present in 1.5% of patients, whereas its frequency in controls was
2-fold (3%), a difference that did not achieve statistical significance (P = .312). The frequency of FV Leiden was
also lower in patients than in controls (1% vs 4.9%;
P = .019). According to these results, carriers of FV
Leiden show almost a 5-fold decreased risk for intracranial hemorrhage
than those lacking the genetic variant under the same environmental
risk factors.
To our knowledge, the FXIII Leu 34 variant was the first polymorphism
to increase the risk for PIH in the white population, according to
recent data obtained in 62 patients with this disease.9 However, our results in a larger number of patients did not support such a suggestion because the FXIII V34L polymorphism showed a similar
distribution among patients and controls. By contrast, in our
case-control study, we found statistically significant differences in
the prevalence of FVII We then analyzed the involvement of the studied polymorphisms in subtypes of intracranial hemorrhage. The prevalence of FVII polymorphism was shown to be similar in PIH or SAH, suggesting that low levels of FVII could increase the risk for both types of intracranial hemorrhage (Table 2). However, the frequency of FV Leiden was lower in patients with PIH than in those with SAH, indicating that this polymorphism could play a more relevant role in PIH. On the contrary, the prothrombin 20210A/G was not found in any of 60 patients with SAH (Table 2). Finally, the prevalence of the FXIII Leu34 allele was higher in SAH than PIH, though differences did not reach statistical significance (Table 2). We did not detect differences in genotype or allele frequency associated with age, sex, or any of the studied risk factors (hypertension, smoking, or alcohol consumption) (data not shown). Finally, no relation was found between the presence of a polymorphism and the 30-day posthemorrhagic episode survival (data not shown).
During the past 20 years, substantial progress has been made in understanding the multifactorial and multigene nature of hemostatic diseases. It is well established that interactions between environmental and genetic factors determine the risk for a thrombotic episode.13 In bleeding disorders, the frequently observed variability in the phenotypic expression even among persons carrying identical genetic mutations suggests the influence of multiple factors in the pathogenesis of these diseases. Thus, co-inheritance of genetic abnormalities has previously been reported for deficiencies of several coagulation factors, including FVIII and FXI,14 as well as FXI and von Willebrand factor,15 though reports of combined coagulation factor deficiencies are scant. The remarkably high prevalence of FV Leiden in the general population (2%-12%)11 and the procoagulant state associated with this genetic change make FV Leiden a tantalizing possibility as a key factor in bleeding disorders. Certainly, 2 pieces of evidence support a protective role of FV Leiden in hemophilia. "In vitro" studies recreating the condition of moderate to severe hemophilia A and the distinct clinical phenotype of hemophilia with identical mutations in factor VIII but distinct genotypes in FV Leiden suggest that FV Leiden might have a beneficial effect on hemophilia.16,17 Our report is the first one showing a protective role of FV Leiden polymorphism in acquired bleeding disorders, thus providing further evidence of such a potentially protective role of FV Leiden in hemorrhagic diseases. Thus, we found that the presence of FV Leiden reduces by 5-fold the risk for spontaneous intracranial hemorrhage. This result is also in accordance with the suggested protective role of this prothrombotic polymorphism in other bleeding disorders such as the partum.18 Accordingly, the high prevalence of this potentially harmful mutation in the white population could be explained as a consequence of an evolutionary selection mechanism conferring survival advantages in bleeding situations to the carriers of this prothrombotic mutation, as has been previously proposed.11,19-21 This attractive hypothesis could also be applied to the 20210A polymorphism of the prothrombin gene, the second prothrombotic polymorphism identified so far. We observed a lower prevalence of this polymorphism in patients with intracranial hemorrhage (1.5%) than in controls (3.0%). However, the low prevalence of this polymorphism in the white population and the lower prevalence of this genetic change in the prothrombotic state of carriership12 suggest that further studies with larger numbers of participants should be performed. Another example of the dichotomy of the hemostatic system is the
prevalence of FVII in thrombosis and hemorrhage. During the last decade
evidence has accumulated indicating that raised plasma FVII levels
increase the risk for ischemic heart disease, though in other studies
such an association was not evidenced.22 Multiple studies
also investigated the role of common polymorphisms influencing the FVII
plasma levels in thrombotic disorders with conflicting results. Several
well-designed studies have failed to find any association of FVII
polymorphisms and arterial or venous thrombosis.23 However, recent reports suggest that those alleles associated with low
levels of FVII could play a protective role against myocardial infarction.6,7 By contrast, FVII plays a key role in
bleeding disorders. Thus, congenital deficiencies of this protein
predispose to spontaneous bleeding and bleeding after
surgery.24 FVII deficiency displays considerable
phenotypic and molecular heterogeneity. Clinically, patients range from
those without symptoms to those with severe hemorrhagic tendencies
associated with zygosity and FVII level.24 Interestingly,
16% of FVII-deficient homozygotes have episodes of cerebral
hemorrhage.25 Moreover, 70% of the FVII knockout mice had
fatal intra-abdominal bleeding within the first 24 hours, whereas most
of the remaining neonates died of intracranial hemorrhage before the
age of 24 days.26 Recombinant activated factor VII has
become an interesting and effective treatment for multiple bleeding
disorders.27 We herein show the first evidence for the
association of the promoter decamer Del/Ins Genetic polymorphisms underlie the diversity of any specie. Most of such inherited changes in DNA structure are neutral, but others could affect the function of proteins and, with more or less severity, the efficiency of a whole physiological system, thus modifying susceptibility to a particular disease. These genetic changes could have particular strength in very sensitive systems such as the hemostatic system. Because of the dichotomy of this system, polymorphic changes affecting hemostatic factors could have mild but opposite effects in the pathogenesis of thrombotic and hemorrhagic disorders. Our results in patients with intracranial hemorrhage support this assessment for 3 polymorphisms affecting the level or function of 3 relevant clotting factors: II, V, and VII. Thus, one polymorphism conferring a specific procoagulant state could have a distinct pathologic effect, increasing the risk for thrombosis or reducing that of hemorrhage, depending of the presence of specific conditions and other risk factors for thrombosis or bleeding. Similar assessments can be made for a polymorphism with prohemorrhagic consequences, changing the effect for each disease. This new concept opens new perspectives in the investigation of bleeding disorders and in the relevance of polymorphisms affecting hemostatic factors.
We thank M. Serrano, L. Martinez, C. Piqueras, and R. García for the recruitment of patients and controls and M. L. Lozano, J. Rivera, and C. Martínez for helpful discussions.
Submitted November 11, 2000; accepted January 19, 2001.
Supported by FIS 99/1091 and FIS 00/0328. J.C. is Contratado de Investigación FIS-Servicio Murciano de Salud. R.G.-C. is a Postdoctoral Fellow of Universidad de Murcia.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
Reprints: Vicente Vicente, Centro Regional de Hemodonación, Ronda De Garay S/N, 30003 Murcia, Spain; e-mail: vvg{at}um.es.
1. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease study. Lancet. 1997;349:1269-1276[CrossRef][Medline] [Order article via Infotrieve]. 2. Lane DA, Mannucci PM, Bauer KA, et al. Inherited thrombophilia: part 1. Thromb Haemost. 1996;76:651-662[Medline] [Order article via Infotrieve]. 3. Lane DA, Mannucci PM, Bauer KA, et al. Inherited thrombophilia: part 2. Thromb Haemost. 1996;76:824-834[Medline] [Order article via Infotrieve]. 4. Bertina RM, Koeleman BP, Koster T, et al. Mutation in blood coagulation factor V associated with resistance to activated protein C. Nature. 1994;369:64-67[CrossRef][Medline] [Order article via Infotrieve].
5.
Poort SR, Rosendaal FR, Reitsma PH, Bertina RM.
A common genetic variation in the 3'-untranslated region of the prothrombin gene is associated with elevated plasma prothrombin levels and an increase in venous thrombosis.
Blood.
1996;88:3698-3703
6.
Iacoviello L, Di Castelnuovo A, De Knijff P, et al.
Polymorphisms in the coagulation factor VII gene and the risk of myocardial infarction.
N Engl J Med.
1998;338:79-84
7.
Girelli D, Russo C, Ferraresi P, et al.
Polymorphisms in the factor VII gene and the risk of myocardial infarction in patients with coronary artery disease.
N Engl J Med.
2000;343:774-780 8. Adams RD, Victor M, Ropper AH. Cerebrovascular diseases. In: Adams RD,Victor M,Ropper AH, eds. Principles of Neurology. New York, NY: McGraw-Hill; 1997:777-873.
9.
Catto AJ, Kohler HP, Bannan S, Stickland MH, Carter A, Grant PJ.
Factor XIII Val 34 Leu: a novel association with primary intracerebral haemorrhage.
Stroke.
1998;29:813-816
10.
Corral J, González-Conejero R, Iniesta JA, Rivera J, Martínez C, Vicente V.
The FXIII Val34Leu polymorphism in venous and arterial thromboembolism.
Haematologica.
2000;85:293-297 11. Rees DC, Cox M, Clegg JB. World distribution of factor V Leiden. Lancet. 1995;346:1133-1134[CrossRef][Medline] [Order article via Infotrieve]. 12. Bertina RM. The prothrombin 20210G to A variation and thrombosis. Curr Opin Hematol. 1998;5:339-342[Medline] [Order article via Infotrieve]. 13. Bertina RM. Molecular risk factors for thrombosis. Thromb Haemost. 1999;82:601-609[Medline] [Order article via Infotrieve]. 14. Berg LP, Varon D, Martinowitz U, Wieland K, Kakkar VV, Cooper DN. Combined factor VIII/factor XI deficiency may cause intra-familial clinical variability in haemophilia A among Ashkenazi Jews. Blood Coagul Fibrinolysis. 1994;5:59-62[Medline] [Order article via Infotrieve]. 15. Tavori S, Brenner B, Tatarsky I. The effect of combined factor XI deficiency with von Willebrand factor abnormalities on hemorrhagic diathesis. Thromb Haemost. 1990;63:36-38[Medline] [Order article via Infotrieve].
16.
van't Veer C, Golden NJ, Kalafatis M, Simioni P, Bertina RM, Mann KG.
An in vitro analysis of the combination of hemophilia A and factor V Leiden.
Blood.
1997;90:3067-3072
17.
Nichols WC, Amano K, Cacheris PM, et al.
Moderation of hemophilia A phenotype by the factor V R506Q mutation.
Blood.
1996;88:1183-1187 18. Lindqvist PG, Svensson PJ, Dahlbäck B, Marsál K. Factor V Q506 mutation (activated protein C resistance) associated with reduced intrapartum blood loss: a possible evolutionary selection mechanism. Thomb Haemost. 1998;79:69-73[Medline] [Order article via Infotrieve]. 19. Majerus PW. Human genetics: bad blood by mutation. Nature. 1994;369:14-15[CrossRef][Medline] [Order article via Infotrieve]. 20. Dahlbäck B. Physiological anticoagulation: resistance to activated protein C and venous thromboembolism. J Clin Invest. 1994;94:923-927.
21.
Hajjar KA.
Factor V Leiden 22. Meade TW, Ruddock V, Stirling Y, Chakrabarti R, Miller GJ. Fibrinolytic activity, clotting factors, and long-term incidence of ischaemic heart disease in the Northwick Park Heart Study. Lancet. 1993;342:1076-1079[CrossRef][Medline] [Order article via Infotrieve]. 23. Doggen CJ, Manger Cats V, Bertina RM, Reitsma PH, Vandenbroucke JP, Rosendaal FR. A genetic propensity to high factor VII is not associated with the risk of myocardial infarction in men. Thromb Haemost. 1998;80:281-285[Medline] [Order article via Infotrieve]. 24. Mariani G, Lo Coco L, Bernardi F, Pinotti M. Molecular and clinical aspects of factor VII deficiency. Blood Coagul Fibrinolysis. 1998;9:S83-S88. 25. Hedner U, Davie EW. Interaction to hemostasis and the vitamin K-dependent coagulation factors. In: Scriver CR,Beaudet AL,Sly WS,Valle D, eds. The metabolic basis of inherited disease. 6th ed. New York, NY: McGraw-Hill; 1989:2107-2127. 26. Rosen ED, Chan JCY, Idusogie E, et al. Mice lacking factor VII develop normally but suffer fatal perinatal bleeding. Nature. 1997;390:290-294[CrossRef][Medline] [Order article via Infotrieve]. 27. Hedner U. Recombinant activated factor VII as a universal hemostatic agent. Blood Coagul Fibrinolysis. 1998;9:S147-S152.
© 2001 by The American Society of Hematology.
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  M. Franchini and P. M. Mannucci Interactions between genotype and phenotype in bleeding and thrombosis Haematologica, May 1, 2008; 93(5): 649 - 652. [Abstract] [Full Text] [PDF]
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L. Navarro-Nunez, M. L. Lozano, J. Rivera, J. Corral, V. Roldan, R. Gonzalez-Conejero, J. A. Iniesta, J. Montaner, V. Vicente, and C. Martinez The association of the {beta}1-tubulin Q43P polymorphism with intracerebral hemorrhage in men Haematologica, April 1, 2007; 92(4): 513 - 518. [Abstract] [Full Text] [PDF]
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 C. Hartel, I. Konig, S. Koster, E. Kattner, E. Kuhls, H. Kuster, J. Moller, D. Muller, A. Kribs, H. Segerer, et al. Genetic Polymorphisms of Hemostasis Genes and Primary Outcome of Very Low Birth Weight Infants Pediatrics, August 1, 2006; 118(2): 683 - 689. [Abstract] [Full Text] [PDF]
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 W. L. Young and G.-Y. Yang Are There Genetic Influences on Sporadic Brain Arteriovenous Malformations? Stroke, November 1, 2004; 35(11_suppl_1): 2740 - 2745. [Abstract] [Full Text] [PDF]
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J. A. Iniesta, R. Gonzalez-Conejero, C. Piqueras, V. Vicente, and J. Corral Platelet GP IIIa Polymorphism HPA-1 (PlA) Protects Against Subarachnoid Hemorrhage Stroke, October 1, 2004; 35(10): 2282 - 2286. [Abstract] [Full Text] [PDF]
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 R. Gonzalez-Conejero, J. Corral, V. Roldan, C. Martinez, F. Marin, J. Rivera, J. A. Iniesta, M. L. Lozano, P. Marco, and V. Vicente A common polymorphism in the annexin V Kozak sequence (-1C>T) increases translation efficiency and plasma levels of annexin V, and decreases the risk of myocardial infarction in young patients Blood, August 28, 2002; 100(6): 2081 - 2086. [Abstract] [Full Text] [PDF]
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R. A. S. Ariens, T.-S. Lai, J. W. Weisel, C. S. Greenberg, and P. J. Grant Role of factor XIII in fibrin clot formation and effects of genetic polymorphisms Blood, July 18, 2002; 100(3): 743 - 754. [Abstract] [Full Text] [PDF]
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R. Gerlach, F. Tolle, A. Raabe, M. Zimmermann, A. Siegemund, and V. Seifert Increased Risk for Postoperative Hemorrhage After Intracranial Surgery in Patients With Decreased Factor XIII Activity: Implications of a Prospective Study Stroke, June 1, 2002; 33(6): 1618 - 1623. [Abstract] [Full Text] [PDF]
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M. Weger, W. Renner, O. Stanger, O. Schmut, H. Deutschmann, T. C. Wascher, and A. Haas Role of Factor XIII Val34Leu Polymorphism in Retinal Artery Occlusion Stroke, December 1, 2001; 32(12): 2759 - 2761. [Abstract] [Full Text] [PDF]
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A. P. Reiner, S. M. Schwartz, M. B. Frank, W.T. Longstreth Jr, L. A. Hindorff, G. Teramura, F. R. Rosendaal, L. K. Gaur, B. M. Psaty, D. S. Siscovick, et al. Polymorphisms of Coagulation Factor XIII Subunit A and Risk of Nonfatal Hemorrhagic Stroke in Young White Women Editorial Comment Stroke, November 1, 2001; 32(11): 2580 - 2587. [Abstract] [Full Text] [PDF]
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J. N. Hagstrom Factor V Leiden and intracranial hemorrhage Blood, November 1, 2001; 98(9): 2875 - 2875. [Full Text] [PDF]
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 A. J. Catto Genetic aspects of the hemostatic system in cerebrovascular disease Neurology, September 1, 2001; 57(90002): S24 - 30. [Abstract] [Full Text]
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Top
Abstract
Introduction
the resistance to activated protein C, caused mainly by the
R/Q 506 mutation in the factor V gene (FV Leiden), and the G/A
transition at position 20210 in the 3'untranslated region of the
prothrombin gene.