Email updates

Keep up to date with the latest news and content from BMC Neurology and BioMed Central.

Open Access Research article

Functional polymorphisms in matrix metalloproteinases -1, -3, -9 and -12 in relation to cervical artery dissection

Armin Buss1*, Katrin Pech1, Susanne Roelver1, Brunhilde Bloemeke2, Christoph Klotzsch3 and Sebastian Breuer2

Author Affiliations

1 Department of Neurology, Aachen University Medical School, Pauwelsstrasse 30, Aachen, Germany

2 Department of Ecotoxicology and Toxicology, University of Trier, Am Wissenschaftspark 27-29, Trier, Germany

3 Department of Neurology, Schmieder-Kliniken, Zum Tafelholz 8, Allensbach, Germany

For all author emails, please log on.

BMC Neurology 2009, 9:40  doi:10.1186/1471-2377-9-40

The electronic version of this article is the complete one and can be found online at:

Received:17 November 2008
Accepted:9 August 2009
Published:9 August 2009

© 2009 Buss et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Cervical artery dissection is a leading cause of cerebral ischemia in young adults. Morphological investigations have shown alterations in the extracellular matrix (ECM) of affected vessel walls. As matrix metalloproteinases (MMP) play a central role in the regulation of the ECM, an increased expression of these enzymes might lead to the endothelial damage in spontaneous cervical artery dissection (sCAD). Five different DNA polymorphisms in MMP-1, -3, -9 and -12 were tested for their frequency in patients with sCAD and compared with those of a control population.


Blood was sampled from 70 unrelated patients presenting consecutively in the department of neurology of the Aachen University Medical School with sCAD and from 87 control subjects living in the same area as the patients. The MMP polymorphisms were analyzed with hybridization probes using the LightCycler™ (Roche Diagnostics), by sequencing using the ABI 310 Genetic Analyzer (Applied Biosystems) and with the GeneScan program on a ABI 310 Genetic Analyzer.


No statistically significant differences in the allelic distribution were found between sCAD patients and the controls.


Alleles of these 5 functional polymorphisms of MMPs seem not to be associated with structural alterations in the blood vessel wall of sCAD patients. However, this does not exclude a pathogenetic role for MMPs in sCAD via secondary factors such as cytokines that are able to induce these enzymes in cervical blood vessel walls.


Spontaneous cervical artery dissection (sCAD) is a leading cause of cerebral ischemia in young adults [1]. The incidence in the general population is estimated at 2.6 to 2.9 per 100 000 and the mean age of occurrence is 44 to 46 years [2,3]. The reason why these sCADs occur in otherwise healthy-appearing young adults remains poorly understood although numerous risk factors have been postulated such as recent infection [4], hyperhomocysteinemia [5,6], low levels of α1-antitrypsin [7] and hypertension [8]. For most factors, evidence is limited either due to small sample size or conflicting data from different studies [9]. Several arguments suggest a genetic influence in sCAD [10]. Two studies reported the overall presence of a family history of sCAD in 2% to 3% of patients. Secondly, patients with sCAD often present with concomitant arterial abnormalities such as fibromuscular dysplasia or aortic root dilation. Finally, morphological investigations have consistently shown alterations in the extracellular matrix (ECM) of skin biopsies even in patients without known connective tissue disorders. Hereditary monogenic disorders such as vascular Ehlers-Danlos syndrome are rare in sCAD [11,12]. Genetic factors might however play a role as part of a multifactorial predisposition (eg, causing a constitutional weakness of the vessel wall or predisposing the vessel wall to inflammatory processes) [10]. Matrix metalloproteinases (MMP) are interesting candidate genes as they play a central role in the regulation of the ECM and earlier studies in vascular pathologies have already shown evidence for an increased activity of MMPs in the wall of affected blood vessels in aortic dissection [13]. In sCAD patients, a recent study reported higher plasma levels of MMP-2 compared to patients with an ischemic stroke from different reasons [14]. In the present study, we therefore investigated 5 polymorphisms in the promoter region of the MMP genes with a known increased expression rate of the corresponding enzyme as possible risk factors for sCAD [15-19].


In this single centre study, blood was sampled from 70 consecutive unrelated patients who presented with sCAD in the years 1999 to 2003 in the department of neurology of the Aachen University Medical School. The patients comprised 42 men and 28 women (age range 28–70 years; median 48.5 years). The diagnosis of sCAD was based on magnetic resonance imaging angiography and/or digital substraction angiography. Fifty-four patients suffered a dissection of the carotid artery, 16 of the vertebral artery; no cases with multiple cervical artery dissections were included. Patients with known connective tissue disorders such as Ehlers-Danlos syndrome, angiographic signs of fibromuscular dysplasia or assumed traumatic cervical artery dissection were excluded. Eighty-seven german caucasian control subjects of similar age and sex distribution living in the same area as the patients were randomly selected in the Aachen University Blood Bank. The control group comprised 50 men and 37 women (age range 22–68 years; median 48 years). The study was approved by the Aachen University Ethical Committee and written consent was obtained from all participants.

DNA was isolated from EDTA blood using the QIAamp DNA Blood kit (Qiagen, Hilden, Germany). The MMP-1 (-1607 1G/2G) polymorphism (rs1799750) was analyzed with hybridization probes using the LightCycler™ (Roche Diagnostics). Primer and probes were designed by Tib Molbiol (MMP1-Sensor: 5'-GAT TTG AGA ATA AGT CAT AT CTT TCT AAT X, MMP1-Anker: 5'-LC Red640- TTA ACT ACA ATT TCC TCA TCT AAG TGG C p, MMP1proS: 5'-TTC TTA CCC TCT TGA ACT CAC ATG-3', MMP1proAS: 5'-TTC CTC CCC TTA TGG ATT CC-3'). The MMP-3 (-1612 5A/6A, rs3025058), -9 (-1562 C/T, rs3918242) and -12 (-82 A/G, rs2276109) polymorphisms were analyzed by sequencing using the ABI 310 Genetic Analyzer (Applied Biosystems) with a standard protocol. The multiallelic (CA)n microsatellite polymorphism in the MMP-9 gene was analyzed with the GeneScan program on a ABI 310 Genetic Analyzer (FAM-MMP9F: 5'-GAC TTG GCA GTG GAG ACT GCG GGC A-3', MMP9R: 5'-GAC CCC ACC CCT CCT TGA CAG GCA-3'). To avoid inconsistencies between different runs, the 6 most common CA-repeats were cloned, sequenced and used as an internal standard in every run. For statistical analyses, χ2 test was used to determine if the genotypes were in the Hardy-Weinberg equilibrium. Odds ratio and the 95% confidence interval were calculated to test the association of genotype and sCAD.


The results of the genetic analyses are presented in Table 1 and 2. There were no statistically significant differences between patients and controls in the 5 polymorphisms investigated. The genotype distributions for all polymorphisms were compatible with those expected from the Hardy-Weinberg equilibrium, except for MMP-12 in patients.

Table 1. Distribution of Genotypes and Alleles of all single nucleotide polymorphisms

Table 2. Allele frequencies of the MMP-9 multiallelic (CA)n microsatellite polymorphism


MMPs are a family of extracellular zinc- and calcium-dependent endopeptidases that degrade the extracellular matrix and other extracellular proteins [20]. The 23 mammalian MMPs can be placed into sub-groups based on structural similarities and substrate specificity and they are capable of degrading virtually all extracellular proteins. In the present study, 5 polymorphisms in the promoter region of MMP-1, -3, -9 and -12 genes were investigated for a possible genetic association with sCAD. All polymorphisms lead to an increased expression of the corresponding enzyme and might therefore lead to ECM instability in blood vessel walls [15-19]. In an earlier study investigating polymorphisms in the MMP-9 gene, no differences in the allelic distribution of both polymorphisms were found between sCAD patients and controls [21]. In accordance with these results, we could also not detect statistically significant differences in overall frequencies of both the single nucleotide polymorphism and the dinucleotide repeat length polymorphism of the MMP-9 gene. Furthermore, concerning the latter polymorphism, its most active variant of 23 dinucleotide repeats was more frequently found in the control group. The frequencies of the single nucleotide polymorphisms of the MMP-1, -3 and -12 genes which were not previously investigated in sCAD patients were also comparable between the patients and the control group.

The present study did not find a statistically significant association between MMP polymorphisms and sCAD. Due to the relatively small sample size of 70 patients, these negative findings might however be due to insufficient power. As the present results are not sufficient to make a definite statement about the genetic association they need to be replicated in a larger group of patients. This is however hardly possible in single centre studies due to the overall low prevalence of sCAD and will need future multicenter investigations.


The results of the present study do not support the hypothesis that polymorphisms in MMP-1, -3, -9 and -12 leading to an increased expression rate of the corresponding enzyme are susceptibility factors of sCAD. However, this does not exclude a pathogenetic role for MMPs in sCAD via secondary factors such as cytokines that are able to induce these enzymes in cervical blood vessel walls. Secondly, future multicenter studies including larger sample sizes are needed to verify or dismiss the lack of genetic association of the MMP polymorphisms and sCAD found in this pilot trial.


sCAD: spontaneous cervical artery dissection; ECM: Extracellular Matrix; MMP: Matrix Metalloproteinase.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AB designed and coordinated the study and drafted the manuscript. KP and SK carried out the analysis of the polymorphisms. BB participated in the design of the study and helped to draft the manuscript. CK participated in the design of the study, provided specimens and helped to draft the manuscript. SB designed and coordinated the study and drafted the manuscript. All authors read and approved the final manuscript.


  1. Schievink WI: Spontaneous dissection of the carotid and vertebral arteries.

    N Engl J Med 2001, 344(12):898-906. PubMed Abstract | Publisher Full Text OpenURL

  2. Lee VH, Brown RD, Mandrekar JN, Mokri B: Incidence and outcome of cervical artery dissection.

    Neurology 2006, 67:1809-12. PubMed Abstract | Publisher Full Text OpenURL

  3. Touze E, Gauvrit JY, Moulin T, Meder JF, Bracard S, Mas JL: Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study.

    Neurology 2003, 61:1347-51. PubMed Abstract | Publisher Full Text OpenURL

  4. Grau AJ, Buggle F, Ziegler C, Schwarz W, Meuser J, Tasman AJ, Buhler A, Benesch C, Becher H, Hacke W: Association between acute cerebrovascular ischemia and chronic and recurrent infection.

    Stroke 1997, 24:1724-29. OpenURL

  5. Gallai V, Caso V, Paciaroni M, Cardaioli G, Arning E, Bottiglieri T, Parnetti L: Mild hyperhomocyst(e)inemia: a possible risk factor for cervical artery dissection.

    Stroke 2001, 32:714-18. PubMed Abstract | Publisher Full Text OpenURL

  6. Arauz A, Hoyos L, Cantu C, Jara A, Martinez L, Garcia I, Fernandez Mde L, Alonso E: Mild hyperhomocysteinemia and low folate concentrations as risk factors for cervical artery dissection.

    Cerebrovasc Dis 2007, 24:210-14. PubMed Abstract | Publisher Full Text OpenURL

  7. Vila N, Millan M, Ferrer X, Riutort N, Escudero D: Levels of α1-antitrypsin in plasma and risk of spontaneous cervical artery dissections: a case-control study.

    Stroke 2003, 34:E168-69. PubMed Abstract | Publisher Full Text OpenURL

  8. Pezzini A, Caso V, Zanferrari C, Del Zotto E, Paciaroni M, Bertolino C, Grassi M, Agnelli G, Padovani A: Arterial hypertension as risk factor for spontaneous cervical artey dissection. A case-control study.

    J Neurol Neurosurg Psychiatry 2006, 77:95-7. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  9. Rubinstein SM, Peerdemann SM, van Tulder MW, Riphagen I, Haldeman S: A systematic review of the risk factors for cervical artery dissection.

    Stroke 2005, 36:1575-80. PubMed Abstract | Publisher Full Text OpenURL

  10. Debette S, Markus HS: The genetics of cervical artery dissection.

    Stroke 2009, 40(6):e459-66. PubMed Abstract | Publisher Full Text OpenURL

  11. Pepin M, Schwarze U, Superti-Furga A, Byers PH: Clinical and genetic features of Ehlers-Danlos syndrome type IV, the vascular type.

    N Engl J Med 2000, 342:673-80. PubMed Abstract | Publisher Full Text OpenURL

  12. North KN, Whiteman DA, Pepin MG, Byers PH: Cerebrovascular complications in Ehlers-Danlos syndrome type IV.

    Ann Neurol 1995, 38:960-4. PubMed Abstract | Publisher Full Text OpenURL

  13. Koullias GJ, Ravichandran P, Korkolis DP, Rimm DL, Elefteriades JA: Increased tissue microarray matrix metalloproteinase expression favors proteolysis in thoracic aortic aneurysms and dissections.

    Ann Thorac Surg 2004, 78(6):2106-10. PubMed Abstract | Publisher Full Text OpenURL

  14. Guillon B, Peynet J, Bertrand M, Benslamia L, Bousset MG, Tzourio C: Do extracellular-matrix-regulating enzymes play a role in cervical artery dissection?

    Cerebrovasc Dis 2007, 23:299-303. PubMed Abstract | Publisher Full Text OpenURL

  15. Rutter JL, Mitchell TI, Buttici G, Meyers J, Gusella JF, Ozelius LJ, Brinckerhoff CE: A single nucleotide polymorphism in the matrix metalloproteinase-1 promoter creates an Ets binding site and augments transcription.

    Cancer Res 1998, 58:5321-5. PubMed Abstract | Publisher Full Text OpenURL

  16. Ye S, Eriksson P, Hamsten A, Kirkinen M, Humphries SE, Henney AM: Progression of coronary atherosclerosis is associated with a common genetic variant of the human stromelysin-1 promoter which Results in reduced gene expression.

    J Biol Chem 1996, 271:13055-60. PubMed Abstract | Publisher Full Text OpenURL

  17. Zhang B, Ye S, Herrmann SM, Eriksson P, de Maat M, Evans A, Arveiler D, Luc G, Cambien F, Hamsten A, Watkins H, Henney AM: Functional polymorphism in the regulatory region of gelatinase B gene in relation to severity of coronary atherosclerosis.

    Circulation 1999, 99(14):1788-94. PubMed Abstract | Publisher Full Text OpenURL

  18. Peters DG, Kassam A, St Jean PL, Yonas H, Ferrell RE: Functional polymorphism in the matrix metalloproteinase-9 promoter as a potential risk factor for intracranial aneurysm.

    Stroke 1999, 30(12):2612-6. PubMed Abstract | Publisher Full Text OpenURL

  19. Jormsjö S, Ye S, Moritz J, Walter DH, Dimmeler S, Zeiher AM, Henney A, Hamsten A, Eriksson P: Allele-Specific regulation of matrix metalloproteinase-12 gene activity is associated with coronary artery luminal dimensions in diabetic patients with manifest coronary artery disease.

    Circulation Res 2000, 86:998-1003. PubMed Abstract | Publisher Full Text OpenURL

  20. Sternlicht MD, Werb Z: How matrix metalloproteinases regulate cell behavior.

    Annu Rev Cell Dev Biol 2001, 17:463-516. PubMed Abstract | Publisher Full Text OpenURL

  21. Wagner S, Kluge B, Koziol JA, Grau AJ, Grond-Ginsbach C: MMP-9 polymorphisms are not associated with spontaneous cervical artery dissection.

    Stroke 2004, 35(3):e62-e64. PubMed Abstract | Publisher Full Text OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here: