Blood microRNAs as potential diagnostic markers for hemorrhagic stroke

Bridget Martinez, Philip V. Peplow

1 Department of Molecular and Cellular Biology, University of California, Merced, CA, USA

2 Department of Anatomy, University of Otago, Dunedin, New Zealand

Blood microRNAs as potential diagnostic markers for hemorrhagic stroke

Bridget Martinez1,#, Philip V. Peplow2,＊,#

1 Department of Molecular and Cellular Biology, University of California, Merced, CA, USA

2 Department of Anatomy, University of Otago, Dunedin, New Zealand

How to cite this article:Martinez B, Peplow PV (2017) Blood microRNAs as potential diagnostic markers for hemorrhagic stroke. Neural Regen Res 12(1):13-18.

Open access statement:is is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Proper medical treatment of a stroke victim relies on accurate and rapid di ff erentiation between ischemic and hemorrhagic stroke, which in current practice is performed by computerized tomography (CT) or magnetic resonance imaging (MRI) scans. A panel of microRNAs could be an extremely useful clinical tool for distinguishing between hemorrhagic and ischemic stroke.is review has shown that blood miRNA pro fi le can distinguish hemorrhagic from ischemic stroke in patients and in experimental animal models. It also seems likely they can differentiate between intracerebral and subarachnoid hemorrhage stroke.e miRNA pro fi le in cerebrospinal fl uid could be a useful diagnostic tool for subarachnoid hemorrhagic stroke. Decreased or increased miRNA levels may be needed either as prevention or treatment of stroke. Administrationin vivoof miR‐130a inhibitor or miRNA mimic (miR‐367, miR‐223) in an intracerebral hemorrhage animal model improved neurological outcomes.

blood microRNAs; diagnostic biomarkers; hemorrhagic stroke; human patients; rat and mouse models

Accepted: 2017-01-14

Introduction

Strokes can be broadly classi fi ed as ischemic or hemorrhag‐ic. Hemorrhagic strokes account for about 20% of all strokes and are divided into categories depending on the site and cause of bleeding. In intracerebral hemorrhage (ICH), bleed‐ing occurs from a ruptured blood vessel within the brain. Hypertension, excessive alcohol intake, and advanced age are all important risk factors. Ischemic strokes can convert to an ICH (Berger et al., 2001), and may be associated with infective endocarditis (Morris et al., 2014). A subarach‐noid hemorrhage (SAH) involves bleeding from a damaged blood vessel causing blood to accumulate at the surface of the brain. Most oen, a SAH happens because of a leaking saccular aneurysm. Hemorrhagic stroke is life threatening with up to 50% of all people with ICH dying, many within the fi rst two days. Surgical removal of the hematoma as an early‐stage treatment for ICH may improve long‐term prog‐nosis (Morgenstern et al., 1998), but no effective targeted therapy for hemorrhagic stroke exists yet. ICH is more likely to result in death or major disability than ischemic stroke or SAH. The sudden buildup of pressure outside the brain in SAH may cause loss of consciousness or death.

Proper medical treatment of a stroke victim relies on accu‐rate and rapid differentiation between ischemic and hemor‐rhagic stroke. Not only do ischemic and hemorrhagic stroke have completely divergent therapeutic options, the treatment itself can convert ischemic stroke to hemorrhagic stroke (Zhang et al., 2014). Clinically, it is therefore crucial to monitor and distinguish ischemiaversushemorrhage stroke within the fi rst week of symptom onset to prevent adverse outcome. Also it is important to distinguish between ICH and SAH as this will in fl uence possible treatment. In current practice, diagnosis of hemorrhageversusischemia stroke is performed by computer‐ized tomography (CT) or magnetic resonance imaging (MRI) scans. There is a need for a reliable, relatively inexpensive method for di ff erentiating between ischemic and hemorrhagic stroke in patients ‐ potentially a point‐of‐care assay that can be performed on a daily basis within the first week of stroke onset. Most biomarkers associated with stroke and proposed as diagnostics in the emergency room for acute stroke are blood‐borne proteins of tissue injury such as C‐reactive protein, ma‐trix metallopeptidase 9, D‐dimer, S100β protein, and B‐type natriuric peptide (Lopez et al., 2012).

MicroRNAs are small non‐coding RNAs of approximate‐ly 22 nucleotides long, involved in the regulation of gene expression, thus controlling a range of physiological and pathological functions such as development, differentia‐tion, apoptosis and metabolism (Ambros, 2004). It has been shown that serum or plasma miRNAs are stable and indic‐ative of the disease state (Chen et al., 2008). Recently much interest has developed in the use of circulating cell‐free miRNAs as novel markers in the clinical diagnosis of disease especially in cancer (Ho et al., 2010). This article reviews recent human and animal studies of miRNAs as biomarkers of hemorrhagic stroke, and whether specific miRNAs, or a combination, can be used to distinguish between ischemic and hemorrhagic stroke.

MicroRNAs in Hemorrhagic Stroke

Leung et al. (2014) compared miR‐124‐3p and miR‐16 plas‐ma levels in 93 stroke patients, median age 72 years, 51% male. Ischemic stroke was diagnosed in 74 patients and 19 patients were diagnosed with hemorrhagic stroke, with blood samples being collected within 24 hours of symptom onset. Twenty‐three age‐ and sex‐matched healthy individ‐uals were recruited as controls. Hypertension was a major stroke risk factor in the patients. Hemorrhagic stroke pa‐tients had higher median plasma miR‐124‐3p levels than ischemic stroke patients and healthy controls (1.94 and 2.55 fold change, respectively).e median plasma level of miR‐16 was increased in ischemic stroke patients compared with hemorrhagic stroke patients and healthy controls (1.24 and 1.35 fold change, respectively). This study did not indicate the number of hemorrhagic stroke patients diagnosed with ICH or SAH, and therefore it is not known whether plasma levels of miR‐124‐3p and miR‐16 can di ff erentiate between these two categories.e fi ndings from ICH and SAH stud‐ies are summarized inables 1 and 2, respectively.

Intracerebral hemorrhage

Human studies

Four clinical studies were found.ey indicated that serum miR‐130a, or a panel of blood speci fi c miRNAs, could dis‐tinguish ICH patients from controls. Additionally, plasma miR‐29c and miR‐122 could distinguish between hematoma enlargement group and non‐hematoma enlargement group of ICH patients.

Animal studies

Three studies had been performed with ICH rats and one study with ICH mice. Inhibition of miR‐130a or enhance‐ment of miR‐367 or miR‐223 had positive outcome by inhib‐iting in fl ammation (able 1).

Subarachnoid hemorrhage

Human studies

Four clinical studies were found. Blood miR‐132 and miR‐324 could differentiate SAH patients with delayed cerebral infarction and SAH patients with non‐delayed cerebral infarction from controls. Also a panel of specific miRNAs in cerebrospinal fl uid could distinguish SAH patients from controls, and SAH patients with no vasospasm from SAH patients with vasospasm.

Animal studies

One study in SAH rats showed miR‐30a and miR‐143 might be useful biomarkers for SAH (able 2).

Figure 1 Possible molecular mechanism of miR-367 mimicmediated support of post-stroke recovery in intracerebral hemorrhage (ICH) mice.

Both increased and decreased miRNA levels may be needed either as prevention or treatment of hemorrhagic stroke. Using an experimental model of ICH, injection of miR‐130a inhib‐itor into the right lateral ventricle before ICH induction in male rats signi fi cantly reduced endogenous expression of miR‐130a, decreased brain edema, and alleviated brain‐blood bar‐rier disruption at 1 day aer ICH. Neurological function was significantly improved (Wang et al., 2016). Also in a mouse model of ICH, intracerebroventricular injection of miR‐367 mimic significantly increased the miR‐367 levelin vivo, and signi fi cantly inhibited interleukin‐1 receptor‐associated kinase 4 (IRAK4), nuclear factor‐κB (NF‐κB), p65, interleukin 6 (IL‐6), IL‐1β and tumor necrosis factor‐alpha (TNF‐α) expression in brain tissues aer ICH, indicating that miR‐367 could in‐hibit in fl ammatory responsein vivo. A miR‐367 mimic signi fi‐cantly decreased brain edema and neurological injury (Yuan et al., 2015; Figure 1). Overexpression of mir‐223 following in‐tracerebroventricular injection of miR‐223 mimic in ICH mice resulted in reduced brain edema, and improved neurological functions. MiR‐223 significantly inhibited caspase‐1 p20, NLRP3, TNF‐α, IL‐1β, and IL‐6 expression in brain tissues aer ICH, showing that miR‐223 could inhibit in fl ammatory responsein vivo(Yang et al., 2015).

Future Perspectives

Numerous circulating miRNAs have been reported to have a potential value in diagnosis of hemorrhagic stroke, with considerable variation in findings. Most of the studies had performed RT‐PCR to validate changes in miRNAs detected by microarray analysis. In several studies, changes in spe‐ci fi c miRNAs were con fi rmed in experimental hemorrhagic stroke in healthy rats or mice.e fi ndings of previous clin‐ical studies need to be repeated in other hospital centers and include both male and female patients. Also experimental animal studies should be performed with hemorrhagic stroke rats or mice of both sexes, and to use antagomirs or mimicsto decrease or increase miRNAs, respectively. As most hem‐orrhagic stroke patients have existing comorbidities and are aged ≥ 50 years, con fi rmation studies should involve animal models with hypertension, hyperlipidemia, diabetes mellitus, and aging.e clinical study by Leung et al. (2014) and the experimental animal study by Liu et al. (2010) have shown that miRNA pro fi le can distinguish hemorrhagic stroke from ischemic stroke.e reported miRNA pro fi les in the studies reviewed would suggest that they can di ff erentiate between ICH and SAH, and clinical studies should be performed to con fi rm this.

Con fl icts of interest:None declared.

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Philip V. Peplow, Ph.D., phil.peplow@otago.ac.nz.

10.4103/1673-5374.198965

＊< class="emphasis_italic">Correspondence to: Philip V. Peplow, Ph.D., phil.peplow@otago.ac.nz.

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