Annals of Clinical and Medical

Case Reports

Review Article ISSN 2639-8109 Volume 14

Tryptophan Metabolism and Birth Asphyxia: what Implications for Neuro Development?
Galipo O1, Scucces L2, Morganti-Kossmann MC2, Musumeci S3*
1
Department of Pediatrics, University of Catania, Catania, Italy
2
Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash Univer-
sity, Melbourne, VIC, Australia
3
Department of Biomolecular Chemistry, National Research Council [CNR], Catania, Italy
Received: 26 Oct 2024 Copyright:
*
Corresponding author:
Accepted: 23 Nov 2024 ©2024 Musumeci S. This is an open access article
Prof. Musumeci Salvatore,
Published: 29 Nov 2024 distributed under the terms of the Creative Commons
Department of Biomolecular Chemistry, National
J Short Name: ACMCR Attribution License, which permits unrestricted use, dis-
Research Council [CNR]. 95125, Catania, Italy
tribution, and build upon your work non-commercially

Citation:
Keywords: Musumeci S, Tryptophan Metabolism and Birth Asphyx-
Quinolinic acid; Cytokines; Neuroinflammation; ia: what Implications for Neuro Development?. Ann Clin
Newborn; Aasphyxia; Chitotriosidase Med Case Rep. 2024; V14(10): 1-8

In children, perinatal asphyxia remains a frequent cause of dis- Neuroinflammation is one of the major responses elicited by peri-
ability and death. Increase catabolism of tryptophan through the natal asphyxia likely contributing to delayed and aggravated neu-
kynurenine pathway, occurs in human brain and systemic tissues ral injury [2-6].
alongside immune activation. The aim of this study was to deter- The inflammatory cascade comprises the secretion of several im-
mine the interaction between changes of the tryptophan pathway mune mediators, which can alter other molecular pathways. Re-
as well as cerebral and systemic inflammation triggered in asphyx- cent work has shown that pro-inflammatory cytokines enhance
ic neonates and correlate these molecular changes with clinical the metabolism of the amino acid tryptophan [TRP], via the ky-
parameters of asphyxia. The levels of the tryptophan catabolites, nurenine pathway [KP]. Interferon [IFN]-γ in particular has been
kynurenine and quinolinic acid, as well as cytokines were quanti- reported to be a key regulator of the KP [7]. Conversely, studies
fied in CSF and plasma of asphyxic neonates at 0 and 7 days after have shown that TRP plays an important role in regulating immune
birth. Since macrophages and microglial cells are the source of activation. In fact, decrease in TRP levels suppresses the prolifer-
quinolinic acid, we also measured chitotriosidase activity, which is ation of blood mononuclear cells [8] and inhibits allogeneic T-cell
a marker for monocytic activation. Significantly higher concentra- responses [9, 10]. Tryptophan is an essential amino acid required
tions of IL-4, IL-6, IL-8, and IL-10 and a non-significant increase for protein synthesis in all living cells. In blood TRP is normal-
of TNF, IFN-γ were found in CSF of asphyxiated infants at day 1 ly transported across the BBB into the brain by a sodium-inde-
compared to day 7. Most of the inflammatory parameters normal- pendent amino acid transport system. TRP is metabolised into
ized at 7 days, but chitotriosidase activity remained elevated. The kynurenine [KYN] by indoleamine 2,3-dioxygenase [IDO-1] in
children were followed-up for an average of a 4-5 years period, astrocytes, infiltrated macrophages, microglia, dendritic and mast
and only in one case, the evaluation of general movements showed cells. KYN is then further processed into other neuroactive me-
an absent fidgety. tabolites such as kynurenine acid [KYNA], anthranilic acid [AA],
1. Introduction 3-hydroxykynurenine [3HK], 3-hydroxyanthranilic acid [3HAA],
Severe asphyxia during birth is a common event in both term and quinolinic acid [QUIN] and nicotinic acid [NA] [11]. QUIN is a
pre-term neonates. This insult causes irreversible brain damage key end product of the KP that acts as a N-methyl-D-aspartate
with long lasting physical disabilities and mental illnesses [1]. [NMDA] receptor agonist, a known mediator of excitotoxic injury

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Volume 14 Issue 10 -2024 Review Article

and neuronal death, inducing lipid peroxidation, axonal damage dences of severe birth asphyxia and required resuscitation [IPPV
and astrocytic death via various mechanisms [12]. In the brain, [intermittent positive pressure ventilation] and nCPAP [nasal con-
QUIN is highly produced by infiltrating macrophages and activat- tinuous positive airway pressure]] for more than 1 min immediate-
ed microglia and is neurotoxic at concentrations as low as 100 nM. ly after birth coinciding with Apgar scores <5 at 5 min after birth.
Because QUIN depolarises neurons and astrocytes, it also plays a Systemic blood pressure and heart rate were monitored through-
pivotal role in the onset of post-traumatic seizures, which can arise out the admission at the NICU. Within 6 h following admission,
as a consequence of brain hypoxia [13, 14]. These findings have arterial blood was taken for measurement of pH, lactic acid, Ht
implicated QUIN in a variety of central nervous system [CNS] dis- [haematocrit], pCO2, O2 saturation, and FiCO2 [fraction of in-
orders [15-19] with its elevation being associated with rapid death spired CO2]. Lumbar puncture was performed to obtain CSF for
in subjects with brain injury [20]. screening of meningitis infection. The leftover CSF samples fol-
Another important product of the KP is the neuroprotective mol- lowing clinical tests were kept at -70°C until the measurement of
ecule KYNA. By being a NMDA receptor antagonist, QUIN and cytokines, Chit activity and TRP metabolites. Lumbar puncture
KYNA have opposite actions. Under normal condition, the levels was repeated at day 7 and measurements were conducted as in-
of QUIN and KYNA are found in an equilibrium state that does dicated above. This study had received prior approval from the
not exhibit any detrimental effects on brain function. However, institutional human ethics committee and written consents were
in CNS diseases QUIN is produced at higher concentration than obtained from the parents.
KYNA. This excess in QUIN drives TRP metabolism towards 2.2. Multiplex Assay for Cytokines
neurotoxicity [21]. Studies have shown that macrophages are one
The concentration of IL-6, IL-8, IL-10, IFN-γ, and TNF was de-
of the major sources of QUIN production in the brain [22]. Abun-
termined using a Bio-Plex Cytokine Assay System [Bio-Rad, Syd-
dant macrophage infiltration in the brain is a critical element of
ney, Australia] in CSF according to the manufacturer instructions.
immune activation following asphyxia [23]. The accumulation of
In brief, samples [50 μl] or standard and a mixture of cytokine
macrophages is easy to detect in the laboratory environment by
antibody-coupled beads [50 μl] were added into a 96-well filter
standard histology, but it is more challenging to investigate in the
plate in duplicates, mixed and incubated overnight at 4°C. After
in vivo settings, in particular in humans. Therefore, specific prod-
removal of the incubation buffer and washing, a cocktail of bi-
ucts of macrophage activation can function as surrogate markers
otinylated antibodies [against IL-6, IL-8, IL-10, IFN-γ, and TNF]
of their brain accumulation. The human chitotriosidase [Chit] be-
was added in each well to react with cytokines. Fluorescent-tagged
longs to the glycoside hydrolase family 18 and is highly secreted
streptavidin [streptavidin-phycoerythrin] was then added to form-
by fully activated mononuclear cells in all tissues and, to a lesser
ing a complex of bead-cytokine-antibody-fluorescent. The concen-
extent, by peripheral polymorphonuclear leukocytes [20, 24]. Chit
tration of each cytokine was determined by a Bio-Plex Suspension
activity has been identified as a marker for macrophage activation
Array System [Bio-Rad] that quantifies cytokines based on the
in infectious diseases [25], neuroinflammatory diseases [26] and
different colour of beads representing different cytokines and the
stroke [27].
presence of streptavidin-phycoerythrin. Cytokine concentrations
The aim of this study was to determine the interaction between the were automatically calculated by the Bio-Plex Manager software
neurotoxic changes elicited with the alteration of the KP and im- [Bio-Rad] using a standard curve derived from recombinant cy-
mune activation occurring in the brain of neonates suffering from tokine standards.
perinatal asphyxia. Levels of TRP metabolites as well as immune
2.3. Chitotriosidase Activity Assay
mediators and parameter of macrophage activation were measured
Measurement of Chit activity was performed using enzyme ac-
in matching CSF and plasma samples at 1 and 7 days after birth,
tivity assay described previously [28]. Briefly, 5 µl of undiluted
and their levels correlated with biochemical parameters of asphyx-
plasma or 30 µl of CSF were diluted with 100 µl solution con-
ia. The results were also correlated with long-term neurological
taining 22 mM chitotriosidase substrate 4-methylumbelliferyl-be-
scores to explore the potential of QUIN as a prognostic marker of
ta-D-N,N,N-triacetyl-chitotriose [Sigma Chemical Co.] and 0.5 M
brain damage and poor outcome in asphyxic children.
citrate phosphate buffer pH 5.2 for 15 min at 37ºC, as originally
2. Material and Methods
described by Hollak et al [29]. The reaction was stopped with the
2.1. Patients and Sample Collection addition of 2 ml of 0.5 M Na2CO3-NaHCO3 buffer pH 10.7, and
This study included 6 neonates admitted to the NICU [Neonatal the product 4-methylumbelliferone was read on a Hitachi 2500
Intensive Care Unit] of the University of Catania Hospital, Ita- fluorimeter at excitation 365 nm and emissions 450 nm. Chit ac-
ly. All neonates were singleton and born via vaginal delivery at tivity was expressed as nanomoles of substrate hydrolyzed per
term gestation [37 to 41 weeks]. The body weights at birth were millilitre per hour [nmol/ml/h] against standards. Chit activity was
between 2400 to 3900 grams. All 6 babies have shown clear evi- repeated in at least two assays for each sample to obtain media/

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Volume 14 Issue 10 -2024 Review Article

mean values. autosampler [Agilent Technologies]. Finally, QUIN concentration

2.4. Measurement of Tryptophan Metabolites was determined as dihexafluoroisopropyl ester, a derivative of
QUIN.
TRY, KYN, KYNA and 3HAA were quantified using high per-
formance liquid chromatography [HPLC]. CSF and serum sam- 2.5. Assessment of Metabolic Status
ples were extracted using equal volume of 5% trichloroacetic acid The concentrations of glucose, lactate, glycerol and glutamate in
and centrifuged at 2000xg for 15 min to pellet the precipitates. CSF were measured by an ISCUS analyser [CMA Microdialysis,
The supernatants were then removed, filtered before being inject- Sweden] against the standards provided by the manufacturer.
ed into HPLC system. The HPLC consists of a solvent delivery 2.6. Data Analysis
pump [GBC LC1110, Australia], an auto-sampler [Shimadzu SIL-
Since the concentration of cytokines, TRP metabolites, glucose,
10AD, Japan], a solvent degasser [Shimadzu DGU-14A] and a
lactate, glycerol, glutamate and the activity Chit were not normal-
WinChrom chromatography data acquisition system [GBC, Aus-
ly distributed. A Mann Whitney U Test was used for graphic rep-
tralia]. For TRY and KYN, the mobile phase consisted of sodium
resentation and statistical analysis. Data were shown as dot plots
acetate [40 mM] and citric acid [40 mM] adjusted to pH 5 before
for each individual value and presented as median with interquar-
the addition of acetonitrile to a final concentration of 2.5%. This
tile range for comparison, p<0.05 considered significant.
was passed through a 0.45 µm filter [Millipore] using a pump at a
3. Results
flow rate of 1 ml/min. Fifty μl of extracted supernatant or standard
were injected into the HPLC, the metabolites seperated by a C18 3.1. Clinical Physiological Data
column [Onyx Monolothic, Phenomenex, Australia] and quanti- The clinical observations data of these asphyxic neonates enrolled
fied using a photodiode array detector [Shimadzu SPD-M10A] at in the study are summarised in [Table 1]. The children were fol-
absorbance of 278 and 363 nm for TRP and KYN, respectively. lowed-up for an average of 4-5 years period [range 2.5-8 years].
KYNA was measured using the same HPLC setup described above Patient #2 showed an IPV in the basal nuclei by echography [data
except that the detection was performed by a fluorescence detector not shown] while the evaluation of general movements showed
[GBC] at excitation of 344 nm and emission at 388 nm, a polymer- an absent fidgety. In this neonate, the sitting was observed at 11
ic column [20 × 3.2 mm; 5 µm particle size; Polymer Lab] and the months and the walking at 24 months. Bayley Scales of Infant De-
mobile phase consisted of sodium acetate [50 mM], zinc acetate velopment was determined at 65 at 24 months. While the general
[0.25 M] and 5% acetonitrile with pH 6.3 at the flow rate of 1 ml/ movement in some infants showed a normal pattern [Patients #1,
min. 3HAA was measured by a Synergi Hydro column [250 × 4.60 #4, #5], in other newborns [Patients #2, #3 and #6] the general
mm; 4 µm particle size; Phenomenex] connected to a fluorescent movement demonstrated a poor repertoire with absent fidgety. The
detector [GBC, Ex = 320 nm, Em = 420 nm] with mobile phase ability to sit occurred at 8 months in five asphyxic newborns [#1,
containing of 25 mM sodium acetate and 2.5% acetonitrile, pH 5.5 #3, #4 and #6], while in one case [#2] it was first manifest at 11
and a C18 column. months. All children presented a marked delay in walking abili-
QUIN was quantified by gas chromatography–mass spectrometry ty namely at 14 months [#5], 17 months [#1, #4, #6] and 19 and
[GC-MS]. The extracted supernatant of CSF was prepared follow- 24 months [#3 and #2 respectively]. Only one newborn received
ing the procedures described previously [30]. GC-MS was carried breast milk and his Q.I ranged between 62-100 according the other
out by an Agilent Technologies 6890 gas chromatograph, an Agi- development parameters. Biochemical parameters reflecting an-
lent 5973 mass selective detector [Agilent Technologies, Sydney, aerobic metabolism were confirmed by low blood O2 saturation
Australia], a HP-5MS capillary column, a GC oven, and a 7683 [<90%] and pH [<7.00] and high lactate [>9 mM] in blood. These
and other parameters are summarized in [Table 2].

Table 1: Clinical data and neurological follow-up of asphyctic patients.

Gestational Age at Birth Breast Bilirubin Bilirubin Sitting Walking Q.I.

Patients Echography
Delivery (weeks) Weight (g) Milk Day 1 Day 2 (months) (months) (Bayley)

#1 38 2800 yes 1 0.6 8 17 87 IPV diffuse

#2 37 2400 no 1.3 4 11 24 65 IPV basal nuclei
#3 39 3900 no 1.4 3.2 8 19 62 IPV diffuse
#4 39 2660 no 3.9 8.4 8 17 68 Normal
#5 41 3360 no 3 5.3 9 14 100 IPV moderate
#6 40 3200 no 1.3 4 8 17 80 Normal

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Volume 14 Issue 10 -2024 Review Article

Table 2: Clinical and biochemical data of 6 neonates considered asphyctic at birth

Arterial
Lactate Hematocrit PaCO2 HR (beats/
Patients Day pH Sat O2 (%) FiCO2 (%) Pressure
(mM) (%) (mmHg) min)
(mmHg)
#1 0 7.1 9.7 61.3 35.3 91 50 108 65/44
#1 7 7.4 1.4 54 46 95 21 130 64/35
#2 0 7 11.8 61 66.7 91 50 154 84/58
#2 7 7.4 1.2 42 38 95 21 130 64/35
#3 0 6.8 14 60 127 65 90 75 68/29
#3 7 7.4 1.2 42 38 95 21 130 64/35
#4 0 6.9 9 66 70 65 90 75 68/29
#4 7 7.4 1.9 49 38 95 21 130 64/35
#5 0 6.9 9.4 52.6 48.2 91 50 120 56/27
#5 7 7.4 1.1 54 35 94 21 140 56/35
#6 0 7.26 2.3 64.3 58.9 96 30 160 56/24
#6 7 7.4 1.4 54 46 95 21 130 64/35

pCO2: partial pressure of carbon dioxide; sO2: arterial O2 saturation; FiCO2: fractional concentration of inspired CO2; HR: heart rate.

3.2. Cytokine concentration in CSF of Asphyxic Neonates stantial reduction at day 7 [median: 594.1 pg/ml, IQR: 256.2-707.5
Following birth asphyxia, six cytokines [IL-4, IL-6, IL-8, IL-10, pg/ml; median 41.68 pg/ml, IQR: 31.74-70.51 pg/ml; respectively;
IFN-γ, and TNF] were quantified in CSF at 1 and 7 days after birth p<0.05]. IL-6, TNF and IFN-γ were not increased in CSF after
[Table 3]. Amongst them only IL-8 displayed marked changes in asphyxia at either day with the exception of patient #1 who had
all infants with a significant elevation at day 1 followed by a sub- much higher levels of cytokine concentrations than other patients.

Table 3: Cytokine concentrations in cerebrospinal fluid (CSF) and serum at days 1 and 7 of age in 6 post-asphyctic neonates.

Cytokines
CSF Day 1 CSF Day 7 Serum Day 1 Serum Day 7
(pg/ml)
IL-4 0.068 ± 0.063 (0.926) n.d. 0.030 ± 0.016 (0.533) 0.183 ± 0.155 (0.846)

IL-6 242.58 ± 177.68 (0.732) 10.32 ± 5.43 (0.526) 182.34 ± 29.39 (0.161) 34.88 ± 15.59 (0.446)

IL-8 632.03 ± 153.43 (0.242) 49.23 ± 10.30 (0.209) 169.03 ± 92.55 (0.546) 24.74 ± 5.50 (0.222)

IL-10 22.47 ± 10.83 (0.481) 0.90 ± 0.45 (0.5) 1697.50 ± 579.8 (0.341) 62.95 ± 33.54 (0.532)

IFN-γ 18.58 ± 9.97 (0.536) 2.47 ± 0.55 (0.222) 16.33 ± 3.78 (0.231) 11.90 ± 7.03 (0.590)

TNF-α 3.59 ± 2.51 (0.699) 0.62 ± 0.12 (0.193) 4.10 ± 0.79 (0.192) 6.15 ± 4.06 (0.660)

coefficient of variation σ/μ in brackets; n.d.: not detectable

3.3. Evaluation of CSF Energy Metabolism in Asphyxic Neo- significantly at day 7 [median: 20 μM, IQR: 15.5-56.5 μM] indi-
nates cating higher brain cell membrane damage at day 1. There was no
[Table 4] reports values of different metabolic molecules evaluated change in CSF glutamate levels between day 1 and 7, which has
in CSF and serum of all asphyxic neonates. Glucose had similar no association with potential cell membrane damage. CSF glyc-
concentrations in CSF between day 1 and 7, and these values are erol concentration was high on day 1 [195±41µM] and returned
similar to glucose levels in serum of normal babies [31]. In con- to almost normal level by day 7 [32.8±10.2µM]. CSF glutamate
trast, lactate was significantly higher in the CSF at day 1 [median: increased at day 1 after birth as compared with day 7. There was no
6654 μM, IQR: 1825-7959 μM] as compared with day 7 [medi- difference in serum glycerol levels between day 1 and 7, while se-
an: 1126 μM, IQR: 932.6-1255 μM; Fig 2 B]. Instead, significant rum glutamate showed elevated concentration in day 1 after birth.
higher glycerol concentration was observed in the CSF at day 1 CSF and serum lactate and glucose appeared no changes between
after birth [median: 192 μM, IQR: 74-233 μM], then decreased the samples from 2 days.

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Volume 14 Issue 10 -2024 Review Article

Table 4: Metabolite concentrations in cerebrospinal fluid (CSF) and serum at days 1 and 7 of age in 6 post-asphyctic neonates.
Metabolites
CSF Day 1 CSF Day 7 Serum Day 1 Serum Day 7
(µM)
Glucose 2647.8 ± 455.7 (0.172) 1914.3 ± 448.4 (0.234) 3043.3 ± 683.0 (0.224) 3599.7 ± 217.0 (0.060)
Lactate 6287.7 ± 1238.9 (0.197) 1100.2 ± 71.3 (0.647) 7194.0 ± 1357.7 (0.188) 2425.6 ± 824.9 (0.340)
Pyruvate 18.2 ± 5.3 (0.291) 8.0 ± 1.8 (0.225) 77.8 ± 10.4 (0.133) 40.7 ± 18.2 (0.447)
Glycerol 195.0 ± 41.9 (0.214) 32.8 ± 10.2 (0.310) 93.2 ± 11.9 (0.127) 83.8 ± 21.1 (0.251)
Glutamate 5.6 ± 0.9 (0.160) 1.7 ± 0.4 (0.235) 147.3 ± 32.6 (0.221) 164.1 ± 39.7 (0.241)
L/P ratio 552.7 ± 269.6 (0.487) 666.0 ± 442.5 (0.664) 89.8 ± 14.0 (0.155) 77.7 ± 16.6 (0.213)

coefficient of variation σ/μ in brackets.

3.4. Tryptophan Metabolism not associated with changes of other downstream metabolites [i.e.
The median concentration of TRP in CSF at day 1 was lower than 3HAA, KYNA and QUIN] over time [Table 5].
day 7 [0.92 μM vs 3.60 μM], however, the variability of the TRP 3.5. Chitotriosidase Activity in CSF
concentration was quite large among different infants [IQR: 0.74- The median Chit plasma level in asphyxial newborn was 9.86
7.21 μM], as compared with day 7 [0.49-4.67 μM]. The significant nmol/mL/h [IQR: 6.61-13.88 nmol/mL/h] and 5.57 nmol/mL/h at
decrease of KYN in CSF at day 7 as compared with day 1 was day 7 [IQR: 4.39-8.24 nmol/mL/h], the difference did not reach the
significant level [Mann Whitney U test, p=0.082; Table VI].

Table 5: Tryptophan, and kynurenine metabolite concentrations in cerebrospinal fluid (CSF) and serum at days 1 and 7 of age in 6 post-asphyctic
neonates.

Tryptophan and Kynurenine

CSF Day 1 CSF Day 7 Serum Day 1 Serum Day 7
Metabolites (nM)
TRY 3657.2 ± 1521.1 (0.416) 2741.0 ± 864.9 (0.315) 5231.4 ± 620.1 (0.118) 5474.2 ± 524.0 (0.095)

KYN 553.8 ± 65.6 (0.118) 463.6 ± 65.6 (0.141) 5074.8 ± 1222.8 (0.240) 4900 ± 775.7 (0.158)

KYNA 95.7 ± 17.9 (0.187) 97.6 ± 38.3 (0.392) 743.7 ± 187.1 (0.251) 227.5 ± 69.7 (0.306)

3OH-AA 1176.3 ± 195.4 (0.166) 1098.8 ± 205.5 (0.187) 1425.5 ± 122.4 (0.085) 148.7 ± 97.7 (0.657)

QUIN 205.5 ± 64.4 (0.313) 132.2 ± 38.1 (0.288) - -

coefficient of variation σ/μ in brackets.

Table 6: Chit activity in cerebrospinal fluid (CSF) and serum at days 1 and 7 of age in 6 post-asphyctic neonates.

Chit activity CSF Serum

Day 1 Day 7 Day 1 Day 7

Chit 9.19 ± 7.47 6.64 ± 2.67 11.21 ± 6.11 12.98 ±7.57

4. Discussion was proposed utilizing in experimental model the effect of aden-

Increasing evidences have demonstrated significative role of cy- osine A2A receptor antagonist, an inhibitor of quinolinic activity
tokine in the brain as injury mediators in animal models [32-34], [41], or the effect kinurenine 3-hydroxylase inhibitor in rodents
as predictive biomarkers in neurodegenerative diseases [35-38] potentiate the expression of kinurenic acid [42], providing neu-
and inflammation-driven depressive disease [16-19], in adult brain roprotection in neonatal rodents. However, the clinical use of this
injury [39] as well as neonatal brain injury [40]. The metabolism inhibitors did not receive sufficiently guaranties to be proposed in
of tryptophan plays a relevant role in the production of neurotoxic conditions where the quinolinic acid is increases. One of this ap-
substance but in the same time of neuroprotective substances [16]. plication could be the asphictic newborns, subjects with brain trau-
This is a surprising fact but the different link of these two products ma, stroke and other degenerative brain injury. In this context, the
to receptor of glutamate justify the bivalent function in the brain. vulnerability-stress-inflammation model has been supported by
There are some recent studies where the control of this mechanism growing evidence [16-19]. According to the model, genetic land-
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Volume 14 Issue 10 -2024 Review Article

scape predisposes subjects to be easily affected by stress, which ing the validity of such immune molecules as potential prognostic
would show inflammatory responses later in life [16]. In similar markers to classify and predict the outcome following TBI.
way, prenatal maternal stress [e.g., prenatal infection/inflamma- 5. Conclusion
tion, decreased fetal growth, hypoxia-related obstetric compli-
The kynurenine pathway of tryptophan metabolism displays a
cations] has been linked to the development of CNS disease in
Janus face as its derived metabolites can be neurotoxic or neuro-
offspring [43].
protective depending of which cell type is producing them. This
This study revealed that asphyxial newborns have a significant in- is a surprising fact but the different link of these two products to
crease of proinflammatory cytokines in both CSF and in plasma receptor of glutamate justify the bivalent function in the brain [7].
and that this increase was more significant in CSF likely due to
This type of molecules would represent a relevant therapeutic
the presence of activated macrophage and glial cells. The normal-
strategy for limiting damages in asphictic newborns, subjects with
ization of these immunological parameters was demonstrated in 7
brain trauma or stroke and other degenerative brain injuries. How-
days, but the levels of Chit activity remained high due to the per-
ever, the clinical use of this inhibitor did not receive sufficiently
sistence of macrophage and glial cells activation with the function
guaranties to be proposed in conditions where the quinolinic acid
of sweeper or scavenger of detrimental material. In relation to the
is increases.
macrophage activity the quinolinic acid was found significantly in-
At this stage, the determination of cytokines expression profile and
creased in CSF respect plasma and this neurotoxic substance was
kynurenine pathway metabolites in brain damage requires sophis-
maintained over the 7 days of observation especially in CSF. This
ticated, time consuming and often expensive quantitative methods
observation is not surprising because a persistent increase of quin-
but in the future the automation is likely to provide more informa-
olinic acid was reported in the CSF of subject with chronic brain
tion for the treatment of asphyctic newborns and of subjects with
trauma dating a year prior [44].
TBI, preventing the long term disability and cognitive impairment
Within minutes of a traumatic impact, a robust inflammatory
and open new way for the prevention and treatment of these two
response is elicited in the injured brain. The complexity of this
severe pathologies.
post-traumatic sequeal involves a strong cellular response compris-
6. Acknowledgement
ing the activation of resident microglia and astrocytes, as well as
the infiltration of blood leukocytes. The second component regards We thank Giuseppe Rapicavoli for his precious technical assis-
the secretion of immune mediators, which can be divided into the tance in laboratory determination of chitotriosidase.
following sub-groups: the archetypal pro-inflammatory cytokines 7. Authorship Contributions
[IL-1, TNF-α, IL-6], the anti-inflammatory cytokines [IL-4, IL- Olivia Galipo’. conceived the study, Luisa Scucces, performed,
10, and TGF-β1], and the chemotactic cytokines or chemokines, analysed and associated data, Maria Cristina Morganti Kossmann,
which specifically drive the accumulation of parenchymal and pe- performed cytokines analysis and revising it critically for impor-
ripheral immune cells in the injured brain regions [45]. Whilst the tant intellectual content. Salvatore Musumeci, participated in co-
humoral immune response is particularly pronounced in the acute ordination, analysis and in drafting the manuscript.
phase following Traumatic Brain Injury [TBI], the activation of
glial cells seems to be a rather prolonged effect lasting for several References
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fluid or intraparenchymal tissue with initial brain damage, mortal- and cerebrospinal fluid tumour necrosis factor-α and interleukin-1β
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cytokines as biomarkers is not broadly accepted. This article dis- aemic encephalopathy. Archives of Disease in Childhood - Fet
cusses the evidence from both clinical and basic research explor- 5. Sävman K, Blennow M, Gustafson K, Tarkowski E, Hagberg H. Cy-

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