K. Kolev

Hindered dissolution of fibrin formed under mechanical stress

See also Weisel JW. Stressed fibrin lysis. This issue, pp 977–8.

Basic mechanisms and regulation of fibrinolysis

Fibrinolysis appears in many diverse physiological situations, and the components of the system are well established, along with mechanistic details for the individual reactions and some high‐resolution structures. Key questions in understanding the regulation of fibrinolysis surround mechanisms of initiation and propagation, the localization of fibrinolysis reactions to the fibrin clot, and the influence of fibrin structure and clot composition on thrombolysis. This review covers these key areas with a focus on recent developments on fibrin structure and binding, the effects of a variety of cell types, the consequences of histones and DNA released by neutrophils, and the influence of flow. A complete understanding of the regulation of fibrinolysis will come from the building of detailed mathematical models. Suitable models are at an early stage of development, but may improve as model clots increase in complexity to incorporate the components and interactions listed above.

Perturbation of the integrity of the blood-brain barrier by fibrinolytic enzymes

The action of fibrinolytic enzymes (plasmin, miniplasmin, neutrophil leukocyte elastase) on the blood-brain barrier is investigated. The binding and the effects of the fibrinolytic enzymes are studied in the first subcultivation of human brain capillary endothelial cells. 125I-labeled plasmin, miniplasmin and neutrophil leukocyte elastase bind to confluent monolayers of cultured endothelial cells with dissociation constants of 1 × 10-8 mol/l, 4.8 × 10-7 mol/l and 1.8 × 10-8 mol/l, respectively, and the number of binding sites varies between 2.3 × 105 and 7.5 × 106 per cell. Following treatment of the cultured cells with purified and active-site titrated proteases, the changes in morphology of individual cells are analyzed with computerized morphometry. At low concentrations (in nanomolar range) all studied fibrinolytic proteases induce reduction of the cell area; the minimal size is achieved in 20–80 min after the application of an enzyme and the effect is completely reversed in 15 min after its removal. A possible in-vivo consequence of these in-vitro findings is studied in an organ-perfusion model: rat hemisphere is perfused with a protease solution followed by a circulating phase-borne tracer (horse-radish peroxidase). In perfused rat hemisphere, the fibrinolytic enzymes open the blood-brain barrier to the circulation-borne tracer. These results support the concept that fibrinolytic enzymes interact with the brain microvascular endothelium and thus affect the integrity of the blood-brain barrier through active cell contraction.

Neutrophil granulocyte-dependent proteolysis enhances platelet adhesion to the arterial wall under high-shear flow

Summary.  Background: Under high shear stress platelets adhere preferentially to the adventitia layer of the arterial vessel wall in a von Willebrand factor (VWF)‐dependent manner. Objective: The present study was undertaken in an attempt to characterize the structural background of the relative thromboresistance of the media and the impact of neutrophil leukocyte‐derived proteases (matrix metalloproteinases, neutrophil elastase) on platelet adhesion in this layer of the arteries. Methods and results: Platelet adhesion to cross‐sections of the human iliac artery was monitored by indirect immunofluorescent detection of GpIIb/IIIa antigen. Exposure of the vessel wall to activated neutrophils or neutrophil‐derived proteases increased platelet adhesion to the media about tenfold over the control level at 3350 s−1 surface shear rate. In parallel with this enhanced thrombogenicity morphological changes in the media were evidenced by atomic force microscopy (AFM) and scanning electron microscopy (SEM). The fine proteoglycan meshwork seen with Cupromeronic Blue enhancement of the SEM images was removed by the proteolytic treatment and the typical collagen fiber structure was exposed on the AFM images of the media. Conclusion: Through their proteases activated neutrophils degrade proteoglycans, unmask VWF binding sites and thus abolish the thromboresistance of the media in human arteries.

Human cerebral microvessel endothelial cell culture as a model system to study the blood-brain interface in ischemic/hypoxic conditions

Summary1. Cerebral ischemia and reperfusion induce several changes on the endothelial cells at the microcirculatory level.2. Vasogenic brain edema due to compromised blood–brain barrier, transformation of the endothelial cell surface from an anticoagulant to a procoagulant property are important factors in the pathogenesis of ischemic stroke.3. Release of prostaglandins, endothelin-1, complement proteins, and matrix metalloproteinase-9 by microvascular endothelial cells are other components in the complex mechanism of brain ischemia/hypoxia.4. Ultrastructural studies documented the opened paracellular avenues in the course of vasogenic edema in different experimental models.5. Tight junctions of endothelial cells have been characterized with freeze fracture electron microscopy, and the process of transvesiculation was analyzed using rapid freeze and freeze substitution procedure before electron microscopy studies.6. In endothelial cell-culture experiments, we used rodent and later human brains.7. Endothelial cells co-cultured with astroglia resulted in an elaborate tight junctional complex.8. This co-culture technique becomes the basis of in vitro blood–brain barrier studies. On endothelial cells of human brain origin, different regulatory factors found to be responsible for the complex mechanism of ischemic stroke.

Bleeding related to disturbed fibrinolysis.

The components and reactions of the fibrinolysis system are well understood. The pathway has fewer reactants and interactions than coagulation, but the generation of a complete quantitative model is complicated by the need to work at the solid‐liquid interface of fibrin. Diagnostic tools to detect disease states due to malfunctions in the fibrinolysis pathway are also not so well developed as is the case with coagulation. However, there are clearly a number of inherited or acquired pathologies where hyperfibrinolysis is a serious, potentially life‐threatening problem and a number of antifibrinolytc drugs are available to treat hyperfibrinolysis. These topics will be covered in the following review.

Neutralisation of the anti-coagulant effects of heparin by histones in blood plasma and purified systems

Neutrophil extracellular traps (NETs) composed primarily of DNA and histones are a link between infection, inflammation and coagulation. NETs promote coagulation and approaches to destabilise NETs have been explored to reduce thrombosis and treat sepsis. Heparinoids bind histones and we report quantitative studies in plasma and purified systems to better understand physiological consequences. Unfractionated heparin (UFH) was investigated by activated partial thromboplastin time (APTT) and alongside low-molecular-weight heparins (LMWH) in purified systems with thrombin or factor Xa (FXa) and antithrombin (AT) to measure the sensitivity of UFH or LMWH to histones. A method was developed to assess the effectiveness of DNA and non-anticoagulant heparinoids as anti-histones. Histones effectively neutralised UFH, the IC50 value for neutralisation of 0.2 IU/ml UFH was 1.8 µg/ml histones in APTT and 4.6 µg/ml against 0.6 IU/ml UFH in a purified system. Histones also inhibited the activities of LMWHs with thrombin (IC50 6.1 and 11.0 µg/ml histones, for different LMWHs) or FXa (IC50 7.8 and 7.0 µg/ml histones). Direct interactions of UFH and LMWH with DNA and histones were explored by surface plasmon resonance, while rheology studies showed complex effects of histones, UFH and LMWH on clot resilience. A conclusion from these studies is that anticoagulation by UFH and LMWH will be compromised by high affinity binding to circulating histones even in the presence of DNA. A complete understanding of the effects of histones, DNA and heparins on the haemostatic system must include an appreciation of direct effects on fibrin and clot structure.

Lytic and mechanical stability of clots composed of fibrin and blood vessel wall components

Proteases expressed in atherosclerotic plaque lesions generate collagen fragments, release glycosaminoglycans (chondroitin sulfate [CS] and dermatan sulfate [DS]) and expose extracellular matrix (ECM) proteins (e.g. decorin) at sites of fibrin formation.

Heparin modulation of the fibrinolytic activity of plasmin, miniplasmin and neutrophil leukocyte elastase in the presence of plasma protease inhibitors

The effect of heparin on the inactivation rates of fibrin-bound plasmin, miniplasmin and neutrophil leukocyte elastase (PMN-elastase) by their plasma inhibitors was studied. While plasmin and miniplasmin bound to fibrin are not inactivated by antithrombin, heparin (800 nM) makes these enzymes available for the inhibitor; the second-order rate constant increases from zero to 1.3×103 M−1 s−1 and 3.3×103 M−1 s−1, respectively. Heparin slightly increases the rate of fibrin-bound enzyme inactivation by plasmin inhibitor. α1-Protease inhibitor, on the other hand, is unable to inactivate plasmin or miniplasmin bound to fibrin and heparin has no facilitating effect. In the case of PMN-elastase, heparin (300 nM) further increases enzyme protection against α1-protease inhibitor; the rate constant decreases from 41×103 M−1 s−1; to 23×103 M−1 s−1. α2-Macroglobulin inhibits fibrin-bound miniplasmin and PMN-elastase with a second-order rate constant of 1.8×104 M−1 s−1; and heparin (300 nM) increases the rate insignificantly for miniplasmin and by a factor of two for PMN-elastase. It is remarkable that plasmin bound to fibrin is not inhibited by α2-macroglobulin independently of the presence of heparin. On the basts of the reported kinetic data a lifespan of 420 s for plasmin, 66 s for miniplasmin and 4 s for PMN-elastase was calculated, when the enzymes are bound to fibrin in the presence of the four protease inhibitors at physiological plasma concentration. If heparin is present (300 nM) these values decrease to 240 s for plasmin and 42 s for miniplasmin, whereas that of PMN-elastase is unchanged. Thus, the present in vitro kinetic model suggests an antifibrinolytic effect of heparin in a plasma milieu.

Matrix metalloproteinases at key junctions in the pathomechanism of stroke

Matrix metalloproteinases play a crucial role in the remodelling of the extracellular matrix through direct degradation of its structural proteins and control of extracellular signalling. The most common cause of ischemic brain damage is an atherothrombotic lesion in the supplying arteries. The progress of the atherosclerotic plaque development and the related thrombotic complications are mediated in part by matrix metalloproteinases. In addition to their role in the underlying disease, various members of this protease family are upregulated in the acute phase of ischemic brain damage as well as in the post-ischemic brain recovery following stroke. This review summarizes the current understanding of the matrix metalloproteinase-related molecular events at three stages of the ischemic cerebrovascular disease (in the atherosclerotic plaque, in the neurovascular unit of the brain and in the regenerating brain tissue).