Ischemic chronic cardiomyopathy (ICC) is still one of the most common cardiac diseases leading to the development of myocardial ischemia, infarction, or heart failure. The application of several imaging modalities can provide information regarding coronary anatomy, coronary artery disease, myocardial ischemia and tissue characterization. In particular, coronary computed tomography angiography (CCTA) can provide information regarding coronary plaque stenosis, its composition, and the possible evaluation of myocardial ischemia using fractional flow reserve CT or CT perfusion. Cardiac magnetic resonance (CMR) can be used to evaluate cardiac function as well as the presence of ischemia. In addition, CMR can be used to characterize the myocardial tissue of hibernated or infarcted myocardium. Echocardiography is the most widely used technique to achieve information regarding function and myocardial wall motion abnormalities during myocardial ischemia. Nuclear medicine can be used to evaluate perfusion in both qualitative and quantitative assessment. In this review we aim to provide an overview regarding the different noninvasive imaging techniques for the evaluation of ICC, providing information ranging from the anatomical assessment of coronary artery arteries to the assessment of ischemic myocardium and myocardial infarction. In particular this review is going to show the different noninvasive approaches based on the specific clinical history of patients with ICC. Ischemic chronic cardiomyopathy (ICC) still represents one of the most common cardiac diseases that can progress to acute myocardial ischemia or infarction, left ventricle (LV) dysfunction, or heart failure . Currently, a multimodality approach in ICC is appropriate for the correct assessment and management of these patients considering that each technique can have an important role for planning a correct therapeutic strategy ,3,4. Following the ESC guidelines, the role of coronary computed tomography angiography (CCTA) is rapidly increasing given the high negative predictive value of this technique in patients with suspected coronary artery disease (CAD) . AdditioHowever, given the low positive predictive value of CCTA , furtherCardiac Magnetic Resonance (CMR) represents another important noninvasive tool for the assessment of patients with ICC . A singlConsidering the low cost and wide distribution of technique, echocardiography remains the first technique to be used in the patient with ICC. There are multiple advantages of echocardiography compared to other imaging techniques, including its safety, relatively low-cost, and portability which allows for bedside evaluation. According to the European guidelines, rest echocardiography is recommended in all patients in the initial diagnostic management of patients with suspected coronary artery disease (Class I level B) . EchocarStress echocardiography is an established techniqufe, largely used for the assessment of known or suspected CAD with high diagnostic and prognostic value .Regarding nuclear imaging, single photon emission computed tomography (SPECT) is most commonly used for clinical myocardial perfusion imaging, whereas positron emission tomography imaging (PET), is the clinical reference standard for the quantification of myocardial perfusion.In this review, we provide an overview of multimodality imaging approach in patients with ICC, underlying the new development and the future applications of noninvasive imaging. Furthermore, we are going to emphasize the role of each technique based on clinical needs, in order to have a patient-based approach. The role of CCTA for management of suspicious CAD is rapidly increasing following the recommendation of European and American guidelines for the evaluation of patients with stable chest pain ,10.The mDue to the low positive predictive value of CCTA for CAD evaluation, CCTA does not represent the best technique for the evaluation of significant CAD ,11. DespIn terms of stenosis, CT can provide a qualitative or quantitative assessment of coronary stenosis assigning a final CAD-RADS score . The CADIn terms of follow up of patients with ICC, CAD-RADS classification may underestimate the progression of disease . SzilvesPlaque analysis represents another important advantage of CCTA over other noninvasive imaging techniques .The assoCCTA acquisition can provide information about plaque composition. In particular, CCTA can show the presence and extent of positive remodeling index, napkin ring signs, plaque burden, spotty calcification and volume of noncalcified plaque, which are associated with a worse prognosis ,19. Though analysis of plaque could represent an important role in terms of risk stratification, it is extremely important to consider that quantification of plaque components can be different based on the CT scanner  and tubeDespite the fact that the quantification of plaque it is not perfectly reliable, it is important to consider the potential application in the future in terms of follow up of patients with ICC. Different studies coming from the PARADIGM study evaluated changes of coronary artery disease ,22. In pThe role of CCTA can be extremely important in the evaluation of patients that underwent percutaneous coronary intervention  or coronFollow up of intrastent restenosis (ISR) can be extremely difficult but still feasible with CCTA . In partFurthermore, dual-energy technology, using virtual monochromatic images, allows the reduction of streak artifacts and provide iodine maps useful for a better evaluation of intrastent restenosis ,27,28. In those patients that underwent to CABG, CCTA can be extremely helpful for the evaluation of bypass patency ,29. It iCCTA, as mentioned above, can be extremely helpful in patients with ICC for the evaluation of coronary anatomy; however, its role is very limited for the evaluation of hemodynamically significant CAD and it could require further examinations such as stress echocardiography (SE), stress CMR, stress CT perfusion (CTP) or noninvasive imaging with nuclear medicine. Considering the low positive predictive value of CCTA in the presence of a moderate or severe stenosis, additional noninvasive testing could prove to be useful for the assessment of myocardial ischemia . Fractional flow reserve is defined as ratio between the blood pressure distal to a stenosis and the pressure before the stenosis during hyperemia . The appThere are several parameters that identify the FFRct as positive after the application of the FFRct algorithm. Nowadays, the addition of FFRct on top of CCTA allows for the reclassification of patients that underwent CCTA, thus increasing the positive predictive value for depiction of significant CAD ,32. This algorithm allows for the reduction of invasive coronary angiography in order to reclassify the patients based on the functional assessment of the plaque over the anatomical coronary stenosis . Beyond Similar to FFRct, stress CTP, regardless of the static or dynamic acquisition, can be extremely useful for the evaluation of myocardial ischemia over the plaque stenosis ,12,33. Contrarily to FFRct, the stress CTP requires the administration of a stress agent followed by another CT acquisition in single energy or dual energy . The interpretation of static stress CTP is more qualitative or semiquantitative, and it does not allow the evaluation of myocardial blood flow.  The lattFew studies evaluated the prognostic impact of stress CTP in clinical practice ,37,38. Meinel et al. demonstrated that segments deficient of stress CTP are strongly associated with a worse prognosis  while VaIn the setting of ICC, FFRct could have some limitation in clinical practice in patients with previous PCI and stent implantation , but FFRA correct approach using FFRct and stress CTP on top of CCTA can definitely provide identification of ischemic coronary plaques and steer the therapeutical approach. A representative case of FFRct and myocardial perfusion are shown in The goal of noninvasive functional tests for the diagnosis of obstructive CAD is to detect myocardial ischemia . CMR canA typical stress-CMR perfusion protocol is characterized by the administration of a vasodilator during contrast media injection with a series of perfusion sequences acquired at the basal, mid-cavity, and apical slices from the short-axis views.A perfusion defect is defined as a region of subendocardial hypointensity in a coronary distribution. This defect should be evaluated while the myocardium is perfused, rather than immediately upon contrast arrival within the left ventricular cavity  and should last for a few seconds. To differentiate perfusion defects caused by myocardial ischemia or myocardial fibrosis, this assessment must be accompanied by the evaluation of late gadolinium enhancement (LGE) images: the absence of LGE associated with a stress perfusion defect defines the presence of inducible ischemia. The number of segments with perfusion defects may be used to calculate the total ischemic load: according to ESC guidelines , the preFirst, Schwitter et al. reported in 2008 in the MR-IMPACT,  a multicMoreover, this technique has significant prognostic implications: as reported in the SPINS registry , a negatThe main disadvantages of stress-CMR perfusion are its low availability and the high level of expertise required. On the other hand, because of its clinical advantages, lack of ionizing radiation, and low cost, it is a radiological technique that will be used more frequently in the future to study myocardial ischemia, especially considering a more quantitative approach. Furthermore, it could represent a useful tool for the functional assessment on top of CCTA in presence of CAD that requires the evaluation of myocardial ischemia. A case of stress CMR is shown in Despite tissue characterization with CMR in patients with ICC could be obtained without administration of contrast agent using native T1 mapping ,51,52, iLGE sequences are acquired 10–15 min after the administration of gadolinium-based contrast agent ,53. In LThe standard sequences used for the evaluation of LGE are usually T1-weighted gradient echo acquisition reconstructed in magnitude or phase-sensitive ,55. Typical pattern of LGE in ischemic cardiomyopathy is represented by subendocardial LGE that can be extent in transmural scar . However, sometimes it is difficult to differentiate between scar and myocardial blood considering that both of them can appear hyperintense showing the same signal intensity . In ordeIn patients with hibernated myocardium, the absence of LGE or presence of subendocardial LGE with <50% of transmurality is considered viable . The “cuIn the setting of ICC, it is mandatory to evaluate the presence of LGE considering the important role in terms of LV recovery. Despite stress CMR can provide information regarding the myocardial ischemia, the presence of LGE, in the setting of ICC, allows the assessment of infarcted myocardium. This latter information provides the real advantage of CMR over the other techniques such as stress CTP or SE; in particular considering the transmurality of LGE. A representative case has shown in The most widely accepted echocardiographic parameter for LV systolic function assessment is left ventricle ejection fraction (LVEF), a measure derived from volumes assessment, defined as the ratio of stroke volume (end-diastolic volume–end-systolic volume) and end-diastolic volume. Clinical decision-making and patient management in several cardiovascular conditions primarily rely on LVEF ,64,65. IHowever, technical limitations and the dependence of image quality from the acoustic window, with consequent difficulty in distinguishing between the endocardium and the blood pool, make poor LVEF calculated by echocardiography poorly reproducible. In addition, as a volume-derived index, LVEF relies on geometric assumptions , is dependent on load and heart rate, is influenced by changes in LV geometry, and does not correspond to true LV contractility . Interestingly, volumes assessed with echocardiography in patients with ICC have an important diagnostic and prognostic value, independent from LVEF. Left ventricular dilatation at echocardiography is associated with a poor prognosis. In particular, a high end-systolic volume index is predictive of heart failure hospitalization inpatient with ICC . In clinical routine, LV volume measurements are usually obtained in transthoracic echocardiography using the biplane method of disk summation (modified Simpson’s rule) acquiring left ventricle (LV) volume from apical four- and two-chamber views, taking care to maximize LV area, avoiding apex foreshortening. On the contrary, the image acquisition in three-dimensional (3D) echocardiography should focus primarily on including the entire LV within the pyramidal data set as 3D echocardiography does not rely on geometrical assumption. For this reason, 3D echocardiography is recommended nowadays for volumes measurements when feasible, depending on imaging quality. . CompareIn order to partially overcome the limits of LVEF, new parameters have been proposed for the assessment of LV function in echocardiography. Between them, the most used are indices of myocardial deformation obtained with speckle-tracking echocardiography, such as strain and strain rate, proposed as adjunctive parameter to LVEF . Strain As the endocardial layer of the LV wall is more susceptible to ischemic injury in patients with cardiac ischemia, global longitudinal strain (GLS) is more affected than other parameters. It is more effective than LVEF in identifying patients with significant CAD . BieringNotably, the assessment of LV GLS with speckle-tracking echocardiography is related to long-term outcomes in patients with ICC. In a study of 1060 patients with ICC, GLS was independently related to all-cause mortality and heart failure .Thanks to its ubiquitous nature, portability, relatively low cost, and avoidance of ionizing radiation, SE is an attractive choice of test for a wide variety of patients  and has SE is able to detect myocardial ischemia by identification of wall motion abnormalities. Moreover, several prognostic parameters, including blood exercise duration, pressure response, ST-T changes, and LV dilatation, can be simultaneously assessed and enhance its diagnostic and prognostic role. . In termHowever, the test is dependent on the operator experience, and a poor acoustic window can hinder its diagnostic accuracy. Contrast echocardiography can improve image quality, reader confidence, and reproducibility for assessing both LV structure and function. Moreover, in patients with CAD and wall kinesis abnormalities, contrast agents can be used when thrombi are suspected but not clearly documented . In patiSpeckle-tracking echocardiography has also been proposed to reduce the subjectivity of image interpretation in SE. A recent study from Ilardi et al. demonstrated that strain evaluation improves visual wall motion assessment to detect inducible ischemia in the myocardial territories supplied by the left anterior descending artery in patients undergoing dobutamine stress echocardiography . FinallyThe major advantages of echocardiography are still represented by its low cost, wide availability and lack of ionizing radiation. Therefore, the role of echocardiography, in patients with ICC, is still fundamental in clinical practice allowing the evaluation of biventricular function and evaluation of ischemia. A representative case is shown in Myocardial perfusion imaging (MPI) with SPECT is one of the most performed noninvasive cardiac imaging tests. The biggest advantage of SPECT is that there is extensive clinical experience as well as an abundance of studies demonstrating the ability of SPECT in the diagnosis, risk stratification, treatment, and prognostic evaluation for patients with coronary artery disease ,80. ThisSeveral perfusion and nonperfusion markers have been proposed to improve detection of left main or three-vessel coronary disease ,93. Risk82Rb-chloride and13N-ammonia, with a small number of centers worldwide using 15O-water [15O]-water -water . SubsequO]-water ,111, incO]-water ,113. TheO]-water . NoninvaO]-water ,116,117.O]-water ,119. SimO]-water . Noninvasessment ,122. A msessment . The potsessment ,125 as wsessment . In ordeStress imaging with nuclear medicine is widely available in clinical practice, allowing the evaluation of myocardial ischemia. Although stress CTP, myocardial SPECT and myocardial PET require the use of ionizing radiation, it is important to consider that with CTP it is possible to evaluate CAD beyond myocardial ischemia. Compared to SE and stress CMR, using nuclear medicine it is possible to evaluate ischemic myocardium, however it is mandatory to consider the use of radiation. A representative case is shown in Nowadays a multimodality approach represents a fundamental tool for an appropriate management of patients with ICC. The multimodality approach in patients with ICC allows to develop different strategies based on the clinical history of patients and local expertise . The possibility to have a comprehensive and detailed evaluation of coronary plaque anatomy together with assessment of myocardial ischemia allows the possibility to have the best therapeutical approach. Indeed, the sequential strategy, due to a multimodality approach, can be extremely helpful for the correct identification, diagnostic pathway, providing a customized approach based on clinical needs. The future of integrated approach  in ICC will be revolutionized by the revolution of Artificial Intelligence applied to medical imaging . SeveralRadiomics is another interesting topic that will be further developed in the field of cardiovascular imaging ,138. UsiConsidering the aforementioned techniques, noninvasive imaging in patients with ICC is moving to a precision-based approach with a customized treatment, struggling to avoid unnecessary invasive procedures. Another interesting topic that should be underlined in patients with ICC, is the mandatory use of imaging for planning of the best surgical approach and selection of coronaries that should be revascularized. Therefore, it should not surprise that patients will undergo to several imaging techniques before CABG .An important issue that should be further explored in clinical practice is represented by the prognostic significance of plaque analysis versus ischemia for development acute cardiac events. Following the results of ISCHEMIA trial , it coulDespite the role of noninvasive imaging in patients with ICC can be complementary, it is not possible to ignore that in prognostic stratification some information obtained with noninvasive techniques can have different importance.In the future, in spite of multimodality imaging’s role in ICC, it will be extremely important to consider the balance between local expertise, clinical needs and economical sustainability. Considering the new ESC  and ACC In conclusion, a multimodality approach of patients with ICC is fundamental in the modern era for a better evaluation and follow up of CAD. In the future, the combination of data obtained with noninvasive multimodality imaging with AI, radiomics, clinical information according to sustainability and local expertise could play a key role for a better and faster classification and management of these patients.


Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are common acute and severe cases of the respiratory system with complicated pathogenesis and high mortality. Sepsis is the leading indirect cause of ALI/ARDS in the intensive care unit (ICU). The pathogenesis of septic ALI/ARDS is complex and multifactorial. In the development of sepsis, the disruption of the intestinal barrier function, the alteration of gut microbiota, and the translocation of the intestinal microbiome can lead to systemic and local inflammatory responses, which further alter the immune homeostasis in the systemic environment. Disruption of homeostasis may promote and propagate septic ALI/ARDS. In turn, when ALI occurs, elevated levels of inflammatory cytokines and the shift of the lung microbiome may lead to the dysregulation of the intestinal microbiome and the disruption of the intestinal mucosal barrier. Thus, the interaction between the lung and the gut can initiate and potentiate sepsis-induced ALI/ARDS. The gut–lung crosstalk may be a promising potential target for intervention. This article reviews the underlying mechanism of gut-lung crosstalk in septic ALI/ARDS. Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is a life-threatening condition of respiratory failure . ALI/ARDSevere acute inflammation plays a crucial role in septic ALI/ARDS . PathogeThe gut microbiome coexists harmoniously with the host and plays multifarious beneficial roles in the body, such as shaping the immune system, maintaining homeostasis, and others . An incrDuring sepsis, the onset of ALI/ARDS is related to the activation of a complex inflammatory cytokine cascade. The continuous recruitment of inflammatory cells perpetuates a vicious cycle that produces more pro-inflammatory cytokines, which interact with and influence each other to promote severe damage to the alveolar-capillary membrane as well as respiratory failure. Moreover, researchers have broadened the scope of septic ALI/ARDS to another key factor: the lung microbiome. In septic-ALI/ARDS, the inactivation of the bactericidal layer of the alveolar epithelium , the floDuring septic ALI/ARDS, increased cytokine levels may cause impairment of the intestinal barrier. This selective barrier is composed of intestinal mucosal epithelial cells and inter-cell connections. When the selective barrier functions normally, it allows the cell-side movement of water, solutes, and immunomodulatory factors but prevents the movement of macromolecules and microorganisms . Tight jNotably, toll-like receptor 4 (TLR4) is widely expressed in intestinal stem cells and regulates their proliferation or apoptosis . During All in all, an increase of inflammatory cytokines induces gut barrier dysfunction, intestinal hyperpermeability, bacterial translocation, and amplification of the inflammatory responses. Subsequently, this expansion of the systemic inflammatory response contributes to lung injury.Sepsis-associated ALI/ARDS results in the alteration of lung microbiota both in the mice model and in patients. The etiology of pulmonary dysbiosis in sepsis patients is complex and includes endogenous  and external factors . Changes in the lung flora may affect the composition of the gut flora in sepsis-induced ALI/ARDS. One previous study manifested that lung microbiota imbalance in a sepsis-related ALI murine model increased the total bacterial count in the cecum . In clinRuminococcus sp.5_1_39bFAA. The decrease of intestinal bifidobacteria abundance is negatively correlated to WBC , including butyric acid, acetic acid, and propionic acid, are the most abundant and beneficial metabolites of the intestinal flora . SeveralTrimethylamine N-oxide (TMAO) derives primarily from the gut metabolite of choline, carnitine, and phosphatidylcholine . ExcessiOne of the degradation products of flavonoids and amino acids by commensal bacteria is desaminotyrosine DAT; . FlavonoIndoles are metabolites of tryptophan metabolism by microbiota . It is nIt is well known that gut microbiota are able to synthesize vitamin K as well as most water-soluble B vitamins such as thiamine (vitamin B1), riboflavin (vitamin B2), nicotinic acid (vitamin B3), pantothenic acid (vitamin B5), pyridoxine (vitamin B6), cobalamin (vitamin B12), biotin (vitamin H), and folates . The potThe above discussion showed that the changes of the intestinal flora and its metabolites can affect the severity of septic ALI/ARDS by regulating the levels of local and systemic inflammation, oxidative cellular stress, and cell infiltration/activation.Structural and functional disruption of intestinal barrier integrity in sepsis leads to increased intestinal permeability . Three fMacrophages, commonly polarized into M1 (pro-inflammatory) and M2 (anti-inflammatory) types according to responses to environmental stimuli, are key orchestrators in the pathogenesis of ALI/ARDS . In the As the intestinal barrier plays an important role in sepsis-induced lung injury, targeted microbiota has the potential for prevention and treatment of lung injury. Fecal microbiota transplantation (FMT) can help the recipient to establish a normal intestinal microecological environment and may be considered a useful therapy for sepsis in the future. In the last few years, FMT has made great strides in correcting microbiota disorders, repairing the intestinal barrier, and regulating immunity . In the Many aspects of lung injury in sepsis have not been thoroughly studied, and the interaction between intestine and lung in sepsis is still a promising research direction. During septic lung injury, the expression of intestinal tight junction protein, the activity of MLCK, and the regulation of IECs proliferation and apoptosis are altered by cytokine storm, leading to gut hyperpermeability. Increase of the intestinal permeability leads to the translocation of gut microbiota, resulting in intestinal inflammation and a cascade of inflammatory reactions driving acute lung injury. Moreover, lung dysbiosis in sepsis-induced ALI/ARDS may cause gut dysbiosis. And the changes of the intestinal flora and reduction of beneficial metabolites in sepsis promote lung injury exacerbation by regulating local and systemic inflammation. Persistent inflammation leads to devastating consequences. Theoretically, therapies that restore the intestinal integrity, microbiome, and homeostasis balance between the two systems through FMT are efficient, but so far basic research and clinical trials are not sufficient. An in-depth understanding of gut–lung crosstalk may provide clues for the regulation of homeostasis in sepsis and contribute to the development of effective therapies to prevent sepsis-induced ALI/ARDS.XZ developed the manuscript and figures. YL contributed to proofreading and revising. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Spinal cord injury (SCI) has a major impact on affected patients due to its pathological consequences and absence of capacity for self-repair. Currently available therapies are unable to restore lost neural functions. Thus, there is a pressing need to develop novel treatments that will promote functional repair after SCI. Several experimental approaches have been explored to tackle SCI, including the combination of stem cells and 3D bioprinting. Implanted multipotent stem cells with self-renewing capacity and the ability to differentiate to a diversity of cell types are promising candidates for replacing dead cells in injured sites and restoring disrupted neural circuits. However, implanted stem cells need protection from the inflammatory agents in the injured area and support to guide them to appropriate differentiation. Not only are 3D bioprinted scaffolds able to protect stem cells, but they can also promote their differentiation and functional integration at the site of injury. In this review, we showcase some recent advances in the use of stem cells for the treatment of SCI, different types of 3D bioprinting methods, and the combined application of stem cells and 3D bioprinting technique for effective repair of SCI. SCI affects not only patients’ body function but also their socioeconomic conditions, and the disorder is often associated with considerable individual suffering and societal costs ..42].The implantation effects of mesenchymal stem cell progenitors on animals and clinical models of SCI have also been studied. These cells could be obtained from different tissues, such as adipose tissue, bone marrow, or Wharton jelly, easily expanded in vitro due to their multi-lineage differentiation potential and adjusted dendritic cell activity owing to their immunomodulatory and paracrine potential. Since they are hypoimmunogenic, they could result in better regeneration by transferring to lesion sites to protect perineuronal nets and promote neural plasticity .Neural stem cells are another type of stem cells that are being progressively applied in SCI treatment. They are a multipotent subtype of progenitor cells in the nervous system and can be derived from three main sources: primary central nervous system (CNS) tissue, pluripotent stem cells, and somatic cells. Similar to other types of stem cells, they have a self-renewing ability and can easily differentiate into different types of neuronal cells, such as neurons, oligodendrocytes, and astrocytes . After sGenetically modified human NSCs (hNSCs) were applied to detect the stimulating effect of these cells on the functional recovery of the injured spinal cord. The results of MRI tests proved the migration of transplanted cells toward the injury site of the spinal cord that could functionally connect to host neurons and substantially enhance locomotor functions while expressing neural lineage markers. These results imply that the transplantation of these cells could regulate inflammatory cells and glia activation and improve the hyperalgesia that occurred after SCI .Moreover, the combination transplantation of NSCs and human olfactory ensheathing mucosa cells has shown effectiveness in preclinical trials to treat post-traumatic cysts of spinal cord injuries. This co-transplantation improved the hind limbs’ motor activity and led to a cyst size reduction of 4–12% in rats . Some ofDue to the critical role of biomaterial scaffolds in forming a beneficial regeneration microenvironment for repairing injured spinal cord tissues, they have been used as supporting and carrier platforms for stem cells. The combined use of stem cells and scaffolds could facilitate the reconstruction of the microenvironment at the injury site . MoreoveThey should be made of biocompatible materials to improve the attachment and proliferation of cells and to guarantee the lack of immune and cytotoxic reactions. Moreover, these materials should also be biodegradable to ensure the substitution of the scaffold with the regenerated tissue in a specified time.They should have enough mechanical strength to ensure a low-stress level in the lesion region and to prevent collapse in this area throughout regular motion.They should contain an interconnected pore size at the microscale level to mimic the extracellular matrix of the natural tissue and to facilitate waste and nutrient exchange.Finally, they should have electrical conductivity to assist in neurite growth and neuro-regeneration.As discussed in the previous section, the main aspects of SCI cure are the regeneration of functional neurons at the injured area with an adequate connection to the neighborhood tissues and, thus, the restoration of the nerve conduction function . It was The conventional methods used for the production of scaffolds are gas foaming, melt molding, electrospinning, sacrificial templating, and phase separation ,55. Gas In the melt molding technique, a mixture of porogen and polymeric powder is prepared inside the mold and heated under pressure above the polymer glass transition temperature. This heating process leads to the production of a scaffold by making connections between polymer and porogens. Then, the porogens are extracted by immersing the mold in water, and, subsequently, the porous structure is fabricated. Although utilizing this method could produce a porous structure with a controllable shape, the high probability of contamination in the pores could restrict the application of this method .Electrospinning is another interesting method, and it has been widely used in recent research. This technique is based on applying high-voltage electricity to a polymeric solution to fabricate fibrous scaffolds. A suitable scaffold could be prepared by controlling different parameters of the spinning process, thereby providing an appropriate platform for tissue engineering applications. That is, it could present a nanoscale/microscale porous structure that could mimic the natural extracellular matrix of tissues. Moreover, it could contain bioactive factors and functional drugs needed to regenerate the function of a tissue. For instance, this technique could be used in nerve tissue regeneration via the formation of nerve guidance conduits (NGCs), which are suitable for the self-repairing process. The main limitation of this method is the utilization of solvents that could be toxic to live cells. Moreover, the dense fibrous structure of the electrospun scaffold could limit their applications in 3D tissue engineering due to poor cell infiltration ,58.As is well known, most of the techniques mentioned above encounter limitations that could diminish their usage in tissue engineering applications. In recent years, a new powerful technique known as additive manufacturing (AM) has been introduced by scientists for the fabrication of scaffolds and it is widely used in different fields, from aerospace, automobile manufacture, and construction to different areas of medical science, especially tissue engineering. It is based on the fabrication of a 3D structure during a layer-by-layer fabrication process with the help of computer-aided design (CAD) or computer tomography (CT) scan images. This technique was introduced in 1986 by Charles W. Hull, who used stereolithography (SLA) to form 3D systems based on using a preprogrammed computer-controlled moving laser beam. Using AM in tissue engineering could overcome most of the limitations of other techniques via control of the porosity, chemistry, and complexity of the fabricated scaffold .Different types of natural and synthetic polymers, ceramics, and metals could be used to fabricate 3D printed scaffolds. In addition to SLA, several other types of printing methods have been introduced, such as multi-jet modeling (MJM), selective laser sintering (SLS), digital light processing (DLP), laminated object manufacturing (LOM), fused deposition modeling (FDM), and micro-extrusion. SLA and DLP are based on utilizing liquid photopolymer resins and ultraviolet (UV) lasers. MJM is a type of inkjet bioprinting process that is based on the use of print head technologies for layer-by-layer deposition of photo-curable plastic resins. FDM is a simple method that uses thermoplastic filaments for printing; SLS uses a high-power laser to fuse small particles to fabricate 3D structures. LOM is based on the use of sheet materials in the form of stacking layers, and, finally, micro-extrusion is based on utilizing micro-size nozzles for the synthesis of miniaturized scaffolds with enhanced accuracy ,61.Among the various types of AM methods, inject printing, SLA, fused deposition modeling (FDM), and micro-extrusion are the most common and extensively used methods for the production of 3D printed scaffolds . The advAs mentioned in the above section, one of the most important areas where the 3D printing technique could be applied is the fabrication of tissue constructs for regenerative medicine. This type of 3D printing is known as 3D bioprinting, and it is conceptually similar to 3D printing. Generally, in 3D printing, materials such as polymeric resins, metal, plastic, and rubber are used to print the desired structure, while in 3D bioprinting, biological materials or bioinks are employed. Bioinks are typically laden with living human or mammalian cells and usually have growth factors or biomaterial that could increase the bioactivity of scaffolds. Among the mentioned methods, microextrusion, laser-assisted bioprinting, and inkjet bioprinting are suitable for bioprinting applications . In the Before the printing process, one must consider the important features of the bioink  that can affect the quality and morphology of the scaffold and its ability in adsorbing cells, which, in turn, can promote their proliferation. Moreover, the most probable limitations of using bioprinting techniques for regenerative medicine applications are legal, ethical, and social concerns, and, as such, these must be addressed before their utilization in clinical applications .SCI contusions lead to an irregularly shaped cavity in the injury site, which is surrounded by preserved white matter. The ideal way of reducing further damage to the injury site is the insertion of biomaterials in the cavity to improve the treatment process. Bioprinted scaffolds are among the most interesting candidates that could be used as filler in the injury site. They can mimic the structure of the extracellular matrix and promote cell proliferation and tissue regeneration, as well as being able to improve the regrowth of axons in the lesion and restoring neural circuitry .One of the most interesting features of 3D printed scaffolds, which distinguishes them from other type of scaffolds for SCI applications, is the addition of cells in their structure during the synthesis process. This allows for a dense and uniformly distributed structure to be prepared, as well as providing a good microenvironment for cell–cell and cell–scaffold interactions in the lesion region, thereby facilitating neuron regeneration and reinstate neural circuitry . The folTo date, various studies with the aim of identifying a suitable method for the treatment of spinal cord injuries have been conducted. Among such methods, the simultaneous application of 3D bioprinting and stem cells has become the subject of considerable interest. Several types of hydrogels and biomaterials have been used for the fabrication of scaffolds for SCI research . The conBy considering all of the above-mentioned features, Vega and coworkers fabricated a 3D bioprinted scaffold utilizing fibrin-based bioink and human-induced pluripotent stem cells (hiPSCs) to study SCI. They provided structures with more than 81% viable cells, in which the stem cells could be differentiated into motor neurons while expressing the neuronal marker 15 days after culturing .An aligned collagen scaffold was also used with neural stem/progenitor cells (NSPCs) for SCI therapy. It was revealed that NSPCs can fabricate a conducive microenvironment for neuronal regeneration and recovery of functions. The fabricated scaffold could provide support for cellular growth and differentiation and a guide for axonal extension. Moreover, it could promote neuro-regeneration and remyelination. The effect of stem cell source on SCI therapy performance has also been examined via the use of two types of NSPCs (brain-derived NSPCs (hbNSPCs) and spinal cord-derived NSPCs (hscNSPCs). The results revealed that spinal-derived stem cells acted more effectively than brain-derived NSPCs in promoting cell survival and neuronal differentiation and reducing the formation of glial scar and inflammatory agents while also improving the recovery of the locomotor functions in tested animal models  2]..2].The combined use of iPSC-derived neural stem cells (iPSC-NSCs) and activated Schwann cells (ASCs) loaded on polycaprolactone (PCL) scaffolds was examined on an SCI animal model. The results of this study confirmed the cells’ effectiveness in reducing lesion cavity volume and improving the recovery of locomotor. Utilizing ASCs could improve neuronal survival and induce axon myelination. The co-culturing of ASCs by stem cells could accelerate neuron differentiation and enhance nerve ending recovery. In addition, the PCL scaffold has excellent properties, such as mechanical stability, biodegradability, biocompatibility, and high processability, which make it appropriate for cell transplantation .To increase the scaffolds’ physicomechanical performances, it is possible to use composite hydrogels instead of simple ones, thereby benefiting from the advantages of different materials and thus meeting the mechanical and physiological requirements of the host tissues . For insIn a recent study, the combination of NSCs and a 3D bioprinted collagen/silk fibroin scaffold promoted nerve regeneration after SCI in rat models. The results of this study showed a significant effect of the combined use of both factors compared to that of sole factors. Indeed, the combined use of scaffold and stem cells could abundantly regenerate axons, reduce glial scarring, and elevate the amounts of neurological scores .In another study, the extrusion method was used for the fabrication of a multi-material 3D bioprinting scaffold containing clusters of iPSC-derived spinal neural progenitor cells (sNPCs) and oligodendrocyte progenitor cells (OPCs) . The NPCLiu et al.  used micNeural tissue engineering is an interesting field of science that could facilitate function recovery at the injured site of the nervous system via the use of therapeutic agents. To date, much effort has been made in the field of SCI treatment, and several types of therapeutic methods have been introduced, among which the most interesting are 3D bioprinting scaffolds, which are capable of combining neural grafts with different bioactive factors and cells. The 3D bioprinting technique is a rapidly growing method that could be used in the generation of highly complex scaffolds with the ability of holding stem cells, which are good candidates for the promotion of regeneration of neurons and accelerating the treatment process. Three dimensionally bioprinted scaffolds, which are fabricated via different methods, could overcome the limitations of other methods, such as their high cost, complexity, and risk of immune rejection and activation. On the other hand, they may also have limitations in terms of the types and number of used materials, the resolution of the constructed bioprint, and the maintenance of the viability of stem cells and promotion of their differentiation. Moreover, several aspects must be addressed before a cell type can be distributed as a commercially viable cell source, including safety, efficiency, cost, and the possibility of large-scale manufacturing. Each stem cell type has advantages and disadvantages, and it is still needed to determine which cell type shows the most effective treatment for SCI. Information obtained from stem cell-based treatment studies revealed that the use of stem cells could be a promising alternative for SCI therapy. However, numerous studies are needed to find the optimal bioinks and methods for the combined use of 3D bioprinted scaffolds and stem cells in clinical trials. Moreover, 4D printing, which is a new, effective method of fabricating smart responsive scaffolds that can enhance the dynamic interactions between cells and scaffolds, has also been developed; however, this technique is also in its infancy and warrants further investigation.


Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears . Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation. Obstetric anal sphincter injury affects about 5.7% of primiparous women who deliver vaginally.Most women who sustain OASIS remain asymptomatic, but some of them are at risk for developing incontinence as they age or with future deliveries.Affected women should be referred to a perineal clinic for further investigation, including both traditional and innovative diagnostic techniques.When OASI is diagnosed immediately after vaginal delivery, primary repair represents the mainstay of treatment.Faecal incontinence resulting from an undiagnosed OASI can be addressed by both conservative and operative measures.Traumatic injuries to the anus and perineum can occur for several reasons, including pelvic trauma, sexual intercourse, and iatrogenic injuries, and potentially lead to sphincteric damage.In women, vaginal delivery represents the most common cause of perineal trauma .While anterior perineal trauma, involving the labia, anterior vagina, urethra, or clitoris, is usually associated with little morbidity, posterior perineal trauma, which accounts for any injury to the posterior vaginal wall, perineal muscles or anal sphincter, can lead to more complex damages ,2.Perineal damages following labour and vaginal delivery are mainly sustained by two different mechanisms of injury: tears of the perineal striated muscles and neurogenic damage of the pelvic floor nerve supply.The stretching and compression of the birth canal occurring during the descent of the foetus may lead to demyelination and subsequent denervation of pudendal nerves .The diagnosis of neurogenic injuries is challenging. In the assessment of a sphincter trauma without any damage occurring to the muscles, imaging methods, such as endoanal ultrasound (EAUS) or magnetic resonance imaging (MRI), are of poor utility. Pudendal neuropathy can be detected by neurophysiologic tests, including concentric needle electromyography (EMG) and pudendal nerve motor latency, but their routine use is not recommended, as it does not impact treatment . Indeed,Post-delivery muscular damages are known as obstetric anal sphincter injuries (OASIS).OASIS are also referred to as third- and fourth-degree spontaneous perineal lacerations, according to the currently accepted classification .Despite the increasing attention on OASIS prevention, a noticeable number of vaginal deliveries is still complicated by these damages. The reported incidence of OASIS ranges between 0.5% and 17% ,13,14,15Spontaneous vaginal delivery increases the risk of pelvic floor dysfunction, which is the combination of some or all of the following conditions: urinary and faecal incontinence and pelvic organ prolapse. Conversely, Caesarean section seems to play a protective role in the long term .Caesarean delivery has been shown to provide partial protection for pelvic organ prolapse and, to a lesser degree, urinary incontinence. Nevertheless, delivery exclusively by Caesarean has not as yet been shown to be protective for FI in comparison with vaginal delivery ,19,20.Furthermore, Caesarean section has been associated with increased risks for fertility, future pregnancy, and long-term childhood outcomes .For these reasons, when involving women in the decision making on their mode of delivery, it is of uttermost importance to identify those mothers least susceptible to birth injury and those at high risk of incurring physical damage to their sphincters ,20.Established risk factors for OASIS development  include Unfortunately, most of these risk factors are not modifiable. Some potentially protective measures have been proposed, including intrapartum obstetric manoeuvres. Manual perineal protection and warm compression on the perineum continuously in the second stage of labour appear to reduce the risk of OASIS .The role of episiotomy in preventing OASIS and/or anal incontinence is still a matter of debate, but at present, routine episiotomy is not recommended .In instrumental deliveries or whenever indicated, a mediolateral episiotomy with an angle of 45–60 degrees from the midline should be considered  since itOASIS represents the leading cause of anal incontinence (AI) in women and severely burdens the individual on a psychological, physical, and social level .Moreover, OASIS can lead to short-term consequences, including wound hematoma and wound breakdown, abscess, and recto-vaginal fistulae formation, and to later symptoms, like perineal pain and dyspareunia. Persistent pain and discomfort from perineal trauma may also cause urinary retention and defecation problems.Although most women experiencing sphincter damage during childbirth may remain clinically silent, some of them are at risk for developing incontinence as they age or with future deliveries. To prevent the long-term complications of an undiscovered sphincter injury, effective tools allowing early diagnosis and, therefore, more effective treatment are needed.We aim to provide a review of the diagnosis, management, and treatment of OASIS, focusing on the most recent detective tools and strategies of cure.Since all women having a vaginal delivery are at some risk of sustaining perineal tears, a systematic physical examination should be performed in the immediate post-delivery setting.Accurate clinical assessment, including an inspection of the perineum and a digital rectal exploration, has thus far remained the most appropriate diagnostic tool for early detection of OASIS . HoweverAppropriate sensibilization and training of childbirth professionals remains the mainstay for correct detection of OASIS following delivery. A proper detection of these lesions may depend on the experience of the assessor; structured hands-on workshops are important to improve health professionals’ abilities to identify and repair the internal sphincter correctly ,29,30.Acceptance that injury is not a medical mistake but often an inevitable complication of childbirth is mandatory in order to let professionals do their best to detect and fix it.The frequency of undiagnosed injuries also underscores the need for imaging in the evaluation of the anal sphincter.More advanced diagnostics  are not The role of imaging in the early diagnosis of OASIS is further limited by the risk of incorrect interpretation of images and consequent potential overestimation of their occurrence ,29,32. IThere is no consensus as to which women benefit from additional imaging; imaging decisions are based on provider preference and equipment availability.EAUS represents the gold standard method for the detection of both external and internal anal sphincter injuries as well as for the evaluation of the injury site and extent of damage .Three-dimensional EAUS (3D-EAUS) permits the detection of even small sphincter injuries otherwise invisible or misinterpreted ,36.EAUS is an accurate, highly sensitive, and safe way of assessing the perineum for OASIS, with none or minimal discomfort for the mother (depending on the size of the probe chosen for the exam) ,38,39.It also allows to assess which injuries are more likely to benefit from a surgical repair and to identify the exact location of the snapped ends of the anal sphincter, potentially playing a role in the intraoperative setting.Though its role has not been clearly determined yet, EAUS can be used in the early follow-up after anal sphincter repair for OASIS to identify patients at higher risk of long-term complications who may benefit from early referral to specialist centres ,40.It may also serve as a helpful tool to plan the mode of delivery in women at risk of developing incontinence with future pregnancies ,42.TPUS consists in the application of a high-frequency curved array transducer on the perineum  to assess the functional anatomy of the pelvic floor and detect anal sphincter abnormalities. In comparison to EAUS, it has the advantages of being more accessible, less invasive, and more acceptable to the patient, being exo-anal. For such reasons, TPUS has become increasingly popular in recent years ,43,44. OEven though TPUS has not yet achieved the same results in terms of images quality when compared to the current gold standard technique, more and more studies are observing a good correlation between these two techniques .Regardless of the adopted approach, the use of ultrasound diagnostics in the obstetric wards is significantly limited by the inter-observer variability and the extensive knowledge and experience needed to detect anal sphincter injuries with these methods.The use of both endoanal and external MRI to detect anal sphincter injuries has been investigated. When compared to EAUS, endoanal MRI demonstrates a lower sensitivity in diagnosing internal anal sphincter defects, while the two methods are comparable for the assessment of the external anal sphincter ,50,51.A recent study comparing external phased array MRI with EAUS observed that the former is more sensitive in detecting external anal sphincter defects and represents a feasible tool in the diagnosis of OASIS .MRI has the advantages of being non-invasive, reproducible, not operator-dependent, and providing objective findings, thus allowing comparison between study populations.In centres where EAUS is not available while MRI is, it may help in making the diagnosis, particularly if there is concern for fistula .In the study of pelvic floor disorders in general, dynamic MR defecography represents another reliable option for non-invasive evaluation of the entire pelvic floor.For anal incontinence alone, most of the times caused by direct sphincter laceration or indirect nerve damage from previous vaginal delivery, MR defecography has little to offer besides showing inability to retain the rectal contrast .Therefore, for anatomic OASIS detection, pelvic MR or ultrasonography are better suited , while fHowever, the use of MR defecography could be justified during the study of patients presenting with faecal incontinence long after delivery to investigate whether it could be ascribed to an end-stage descending perineal syndrome, which would change the surgical approach .Anorectal manometry represents the gold standard for assessing anal sphincter function . It is pAnorectal physiology testing detects absent or impaired anal sphincter function, which can indicate prior sphincter trauma, but such findings are not exclusive to OASIS.Until recently, the lack of standards for both examination performance and the interpretation of the results constituted an important issue related to this exam. However, the International Anorectal Physiology Working Group (IAPWG) has just solved this problem, publishing a standardized protocol for the preparation and performance of anorectal function testing and a language to describe the results of diagnostic tests (London Protocol), which is currently in force .Now, the examination’s inconvenience remains its length, nuisance, and low availability, as it is a highly specialized diagnostic.The need for a simple, useful tool for early diagnosis, usable even by untrained operators, remains unmet. Recently, an option proposed to address this problem is impedance spectroscopy.The electrical impedance is physical property of tissue and, in the perianal area, can reflect the condition of the anal sphincter from both anatomical and functional perspectives. Impedance spectroscopy provides information with respect to a wide range of frequencies corresponding to different depths of the tissues.It is performed through a system consisting of an impedance spectroscope, a dedicated anal probe, and a machine-learning module to interpret test results.This exam represents a novel, non-invasive technique, and it appears to be safe and reproducible, with high sensitivity and specificity in detecting anal sphincter injuries, causing no additional discomfort when compared with physical rectal examination ,59. FurtThe application of impedance spectroscopy in medical practice must be considered as an early screening method for OASIS, complementing the physical examination, rather than an alternative to EAUS, which remains the gold standard of advanced diagnostics.A prospective, multicentre study (ONIRY) comparing performances of impedance spectroscopy with those of EAUS and high frequency anal manometry is ongoing.As stated before, the main risk of an undiscovered sphincter injury is the development of anal incontinence (AI), which can occur long after delivery. AI can range from the involuntary passage of flatus to complete evacuation of liquid or solid faecal matter, thus affecting quality of life with different degrees of severity. The standardized assessment of severity of AI symptoms could be helpful to allow a better evaluation of these patients and to identify those with more severe disease or sphincter defects who may benefit from more invasive procedures. To this purpose, several scoring systems have been proposed. Most of these scores include similar criteria, such as the nature of the incontinence, the degree of loss awareness, the quantity of loss, the frequency of the episodes, and eventual accompanying complaints.Some of the most widely spread incontinence scores are the Wexner Cleveland Clinic Florida Score , the St.If OASIS is diagnosed following vaginal delivery, surgical repair is carried out as soon as possible after childbirth and is defined as a primary repair, representing the mainstay of treatment. When resources for immediate repair are not available, OASIS repair may be delayed for up to 12 h without apparent detrimental effect .The goal of sphincter repair (either primary or secondary) is to restore a functioning anal canal by reconstruction of a muscular cylinder that is at least 2 cm thick and 3 cm long .Meticulous haemostasis and anatomic approximation with a multilayer closure of all disrupted tissue layers are the key principles for preventing complications and restoring faecal competence.Tears involving the IAS  should be properly identified and repaired separately using the end-to-end technique with interrupted or mattress sutures; reapproximating this layer is important for achieving anal continence.There are two recognized methods for the repair of a damaged EAS: end-to-end (approximation) and overlap repair .In a partial thickness EAS tear , an end-to-end repair should be performed by the end-to-end method since the overlapping of partial thickness EAS tears would exert undue tension on the repair. The torn ends of the EAS are approximated and sutured, using interrupted or figure-of-eight sutures .The overlap technique can only be used for full-thickness tears, as two free ends of the muscle are needed for a proper tension-free overlap repair. The torn ends of the EAS are brought together and sutured by overlapping 1 to 1.5 cm of the muscle ends, one over the other, in a double-breasted fashion .A 2013 meta-analysis did not observe significant differences in the overall rate of perineal pain, dyspareunia, flatus incontinence, and FI between the two repair techniques; the overlap group showed significantly lower relative risk of FI at 12 months compared to the end-to-end group .A subsequent randomized trial  comparinThe absence of clear evidence favouring one technique over the other indicates that the practitioner can perform either an end-to-end or overlap repair of the EAS at their clinical discretion.After anal sphincter repair for OASIS, clinical follow-up at 6 to 12 weeks after delivery is recommended [When possible, women with incontinence or pain at follow-up should be referred to a regional dedicated multidisciplinary perineal or pelvic floor clinic for endoanal ultrasonography and anorectal manometry; otherwise, referral to a specialist gynaecologists or colorectal surgeon is an appropriate alternative.FI after OASIS can occur several years after the initial sphincter injury. It may result both from an undiagnosed anal sphincter injury and from a functional failure of sphincteroplasty. Regardless of the cause, management of FI is challenging and should be individualized. Treatment options include various conservative and interventional measures . As repoMedical and behavioural measures represent the first-line therapy of FI. Optimization of stool consistency and reduction of bowel motility through changes in dietary habits, fluid intake management, and pharmacological treatments have proven to be effective . Among pPelvic floor physical therapy (PFPT) is a non-invasive treatment that should be considered as a complementary approach when the aforementioned measures are insufficient.PFPT may involve manual therapy, biofeedback  or electrical stimulation (ES), behavioural education, and home exercise programs. PFPT has robust, evidence-based support as a first-line, minimally invasive option to treat pelvic floor dysfunction, including pelvic organ prolapse (POP), faecal or urinary incontinence, peripartum and postpartum pelvic floor dysfunction, and chronic pelvic pain .The difficulty in early diagnosis of OASIS often prevents provision of the appropriate treatments in the first 12 h from the lesion occurrence, which represents the timeframe associated with the higher chance of cure. Given the non-invasive nature of PFPT, its low cost, and the possibility to perform it individually at home, it could be reasonable to recommend this treatment to all women at high risk for the development of OASIS.Although some studies demonstrated that performing individually adapted PFPT on a regular basis may reduce postpartum AI symptoms , more evSince the internal anal sphincter consists of smooth muscles and is thus not amenable to voluntary exercises, electrical stimulation could represent a strategy to improve the strength and coordination of these smooth and slow muscular components. The underlying mechanism of electrical nerve stimulation possibly involves a neuro-regenerative response through the upregulation of neurotrophic factors in the motoneurons. This technique may therefore improve recovery after childbirth and ameliorate symptoms of faecal or urinary incontinence by promoting neuro-regeneration after injury ,73.Of note, the combination of nonsurgical treatments of chronic faecal incontinence, such as electrical stimulation and electromyographic biofeedback , appeared to be superior to biofeedback alone .Reconstructive surgery, which is carried out several months or years after the initial sphincter injury, is referred to as secondary repair. It follows the same principles of primary repair, and it can be performed either by colorectal surgeons or by appropriately trained gynaecologists. Repeat sphincter repair after a failed primary reconstructive surgery should be considered only if other treatment modalities have been ineffective or if there is an identifiable factor responsible for failure .Sacral nerve modulation (SNM) is a minimally invasive, effective, and sustainable treatment and represents a reasonable first-line surgical option for FI .This technique enhances the impaired sphincter function by continuous, pulsating electrical stimulation of the sacral nerves.Regardless of FI aetiology , SNM has been consistently demonstrated to be effective in improving the continence mechanism ,74.However, patients should be correctly informed about the common adverse events  and the need of reinterventions in the long term (revision or reimplantation needed in 24% of patients at five years) ,76.Perianal injection of bulking agents consists of the inoculation of biocompatible compounds into the submucosal or inter-sphincteric space of the anal canal . It may have some short-term benefit, but to date, little evidence supports its use in the treatment of FI .Artificial bowel sphincter implantation may represent an option of treatment in highly selective patients with severe FI for whom all other treatments have failed.Currently available implants are fluid-filled cuffs. Artificial bowel sphincters seems as effective as SNS in improving continence and quality of life and superior in improving incontinence scores when compared to placebo, medical management, BF-PFPT plus medical management, tibial nerve stimulation, and other non-surgical treatments .This technique is burdened by a high rate of complications, such as wound infections or post-operative pain and consecutive re-surgeries. Long-term re-operation rates reach 95%, with definitive ex-plantation rates of 40% .Prerequisites for future devices are the ability of adaptation to the bowel pressure changes as well as the long-term performance of the systems.Faecal diversion with the creation of a colostomy remains an alternative for incontinent patients with a poor quality of life for whom other therapies have failed or are precluded .Other treatments that are not in mainstream use have been described, including radiofrequency energy administration, tibial nerve stimulation, implantation of Tiersch and implantation of magnetic ring, and muscle transposition techniques, such as graciloplasty and gluteoplasty ,80.Regenerative medicine (RM) strategies are increasingly studied as a future treatment option given the unsatisfactory results of conventional treatments for FI.The goal of RM as a therapy for FI is to restore the function of the anal sphincter by targeting smooth and skeletal muscle tissues. Among the various approaches in this field, cell therapy, biomaterials, and tissue engineering are the most promising ones.Cells are transplanted to promote repair and regeneration of tissues both by directly replenishing the tissues and by releasing trophic factors to attract and activate other cells. Biomaterials provide scaffold structure and promote the integration of cells with the host tissue.Current evidence demonstrates better functional and histological results when cells, scaffolds, growth factors, cytokines, or electrostimulation are combined.The available literature on this subject includes articles with a wide variation in the studied groups, interventions, and outcome measurements, thus not yet allowing for univocal conclusions ,82.To improve diagnosis and management of OASIS, a widespread awareness among healthcare professionals on this problem and its related consequences is essential.In the acute setting, thorough examination of the perineum by midwives and physicians is mandatory to assess the anal sphincter for damages.The use of advanced diagnostic tests as an aid to clinical examination is required to improve prompt diagnosis and to enable immediate and appropriate reconstruction.Among the latest proposed techniques, impedance spectroscopy is a promising tool for early diagnosis of OASIS, as it can be easily used also by untrained professionals.During follow-up or in the primary care setting, practitioners should refer women with any symptoms of faecal incontinence and history of obstetric perineal trauma to a dedicated pelvic floor centre or to a gynaecologist or colorectal surgeon.Since none of the traditional options, both operative and non-operative, for the treatment of obstetric trauma-induced faecal incontinence is fully satisfactory, newer strategies have been proposed. The available preclinical studies suggest a promising beneficial effect of regenerative medicine on FI. Further research in this field is needed to translate regenerative medicine in a concrete alternative for the treatment of FI following postdelivery injuries.


Mineral and bone disorder (MBD) is defined as a systemic abnormality of mineral and bone metabolism, which usually accompanies chronic kidney disease (CKD), with subsequent deleterious effects in bone histomorphometry, skeletal growth and strength as well as vascular tissue of children with CKD . In thisHaffner, summarizing the cornerstones of currently recommended clinical measures to optimize growth in children with CKD.Growth retardation constitutes a major complication, which impacts on life quality and aggravates overall kidney disease associated morbidity. Although significant catch-up growth occurs following kidney transplantation (KTx), and is more evident in the youngest patients, growth delay unfortunately may persist . TherefoLopez-Gonzalez et al. extend these practice points and present data from a retrospective single-center study, informing the incidence and risk factors of growth retardation following KTx. More than two thirds of children finally achieved their expected adult height, and this was primarily attributed to the efficient use of growth hormone (rGH) before and following KTx. These findings support the safety and efficacy of rGH therapy as an adjuvant treatment for growth delay in pediatric kidney transplant recipients. As expected, steroid therapy was negatively associated with final height, highlighting the importance for minimization of steroid exposure in pediatric transplant recipients. Finally, height SDS (standard deviation score) at KTx, which was lower in the youngest patients, was the principal association of subsequent growth, raising the special interest in targeted preventive and therapeutic strategies at this vulnerable population.Schmitz et al. studied the impact of enteral calcium intake (Ca-I) on the evaluation of mineral balance in children aged between 0 and 6 years old with CKD. In this retrospective multicenter analysis, children with CKD were prone to both under and overexposure to enteral calcium intake, indicating the need for Ca-I systematic monitoring. Interestingly, enteral Ca-I was significantly negatively correlated to serum PTH, despite no correlation to serum calcium or serum phosphorus, suggesting that enteral Ca-I may serve as a valuable contributive marker of calcium balance and a promising target for more efficient management of secondary hyperparathyroidism.The currently recommended serum biomarkers for monitoring pediatric CKD-MBD include calcium, phosphorus, alkaline phosphatase, parathormone (PTH) and 25-hydroxy vitamin D levels . The rolGrund et al. present a state-of the art review paper regarding the cardiotoxic effects of FGF23 and its contributive role in the development of left ventricular hypertrophy (LVH) in CKD, based on in-vitro, in-vivo and clinical studies. Considering that FGF23 may be not only a biomarker but also a driver of LVH, the authors additionally analyze the emerging strategies targeting the FGF23-αKlotho-axis in order to ameliorate uremic cardiomyopathy. They additionally highlight the relative paucity of clinical data in this area for children with CKD.Since the discovery of fibroblast growth factor 23 (FGF23) in 2000, several investigational studies have been focused on the contribution of this bone-derived hormone in the manifestation of CKD-MBD, and its possible impact on the enhancement of cardiovascular disease , 5. In tKarava et al. provide new insights in the pathogenesis of CKD-MBD. The authors analyze the adipose tissue endocrine effects on mineral balance from experimental and clinical studies and highlight the clinical data supporting a contributive role of obesity on the development of CKD-MBD. In parallel, they describe in detail the contrary modulatory effect of mineral status on adipose tissue metabolism and underline the emerging clinical evidence regarding the role of disturbed mineral balance on CKD related fat loss.In this Research Topic, Karava et al. present the results of a cross-sectional study on the association of secondary hyperparathyroidism with body composition indices in pediatric patients CKD. In this study, serum PTH was positively associated with adiposity in moderate but not in advanced CKD, suggesting that in children with CKD and high adiposity may present secondary hyperparathyroidism earlier in the course of the disease. Moreover, the authors observed a negative association between alfacalcidol index, defined in their study as weekly alfacalcidol dose per PTH level, and muscle wasting in advanced CKD, suggesting that alfacalcidol index may also serve as a marker of nutritional status. Insights from these data regarding the contributive effect of high PTH on muscle wasting and the protective role of active vitamin D supplementation on muscle preservation suggest further studies are needed, to explore the pathogenic mechanisms linking muscle status and mineral balance in CKD with subsequent clinical outcomes (Further, outcomes .Although much has been achieved, management of CKD-MBD remains a clinical challenge for pediatric nephrologist. Further research is required, including large-scale observational studies and well-conducted randomized controlled trials, to evaluate the appropriate therapeutic interventions that will optimize bone health in children with CKD. Moreover, large scales cohort studies are crucial to enlighten the early recognition of the potential adverse effects of CKD-MBD on the other systems, in order to reduce overall morbidity of pediatric patients. Finally, investigations regarding novel pathogenic pathways of CKD-MBD and advanced clinical tools targeting better comprehension of patient mineral status may improve our knowledge toward a more holistic approach of this disorder.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Ischemic stroke accounts for over 80% of all strokes and is one of the leading causes of mortality and permanent disability worldwide. Intravenous administration of recombinant tissue plasminogen activator (rt-PA) is an approved treatment strategy for acute ischemic stroke of large arteries within 4.5 h of onset, and mechanical thrombectomy can be used for large arteries occlusion up to 24 h after onset. Improving diagnostic work up for acute treatment, reducing onset-to-needle time and urgent radiological access angiographic CT images (angioCT) and Magnetic Resonance Imaging (MRI) are real problems for many healthcare systems, which limits the number of patients with good prognosis in real world compared to the results of randomized controlled trials. The applied endovascular procedures demonstrated high efficacy, but some cellular mechanisms, following reperfusion, are still unknown. Changes in the morphology and function of mitochondria associated with reperfusion and ischemia-reperfusion neuronal death are still understudied research fields. Moreover, future research is needed to elucidate the relationship between continuously refined imaging techniques and the variable structure or physical properties of the clot along with vascular permeability and the pleiotropism of ischemic reperfusion lesions in the penumbra, in order to define targeted preventive procedures promoting long-term health benefits. Ischemic stroke is caused by interruption of the blood supply, most often by a blood clot . The hisIschemic stroke annually affects 17 million people worldwide, of which as many as 6 million die, and a significant proportion are permanently burdened with disability ,9,10. IsStudying data collected by Global Burden of Disease, Injuries, and Risk Factors Study 2017 (GBD 2017), including separate estimates of the global burden and trends for each type of stroke, a 2-fold increase was observed in the absolute number of people who had a new stroke, died, survived, or remained disabled after their stroke within the 12 million stroke-related incidents. Most of the stroke burden occurred in low- and middle-income countries, 65% of those stroke cases were ischemic stroke, 26% was primary intracerebral haemorrhage (PICH), and 9% were represented by subarachnoid haemorrhages ,22.The above-mentioned epidemiological data related to the incidence of stroke varies from country to country and fluctuates according to the burden in high-, low-, and mid-dle-income countries. Individual records from hospital stroke units are incomplete and their availability is limited ,24. The One of the reasons for the increase in morbidity in the world is the change in the structure of the population—the high level of aging compared to the number of births. Moreover, in the last two years, COVID-19 pandemic deeply affected stroke management  and, proIn Poland, in 2050, it has been estimated that the society will consist of 11% of people in the pre-working age, 57% in working age, and 32.7% over 65 years . IschemiCurrently approved treatments for acute ischemic stroke (AIS) are mechanical thrombectomy (MT), which accounted for 1.9% of treatments in 2019 in Poland  and 3.5% of treatments in 2020 year   while inCurrent stroke guidelines report that a fast diagnostic protocol, in qualifying stroke patients for acute treatments should be performed . First sA 56-year-old patient with symptoms of ischemic stroke of the right hemisphere which appeared 2 h before admission to the hospital emergency department was demonstrated.https://drive.google.com/file/d/1xRIdjTL7EYZZz0cSCqWGEr49Y2AbPnj9/view?usp=sharing, accessed on 27 February 2022) presents the imaging techniques used in sequence:CT scan without contrast assisted by RAPID software. The scans automatically analyzed (RAPID software) on the ASPECT scale show only old ischemic changes in the left hemisphere of the brain. In the right hemisphere of the brain there are no signs of the presence of hypodense areas that would indicate new areas of stroke.Perfusion CT scan assisted by RAPID software. The reference levels in the RAPID analysis are set according to the criteria developed in the DEFUSE 3 study. The levels of 2 parameters are investigated: CBF  less than 30% compared to the opposite hemisphere indicates necrosis—purple color area, Tmax value greater than 6 sec signifies the area of the penumbra. Additionally, a quantitative analysis is performed. The calculated mismatch is at the level of 1.6, which according to the adopted DEFUSE 3 criteria, should disqualify the patient from mechanical thrombectomy. On the other hand, European recommendations suggest that up to 6 h after the appearance of the first symptoms of the disease, we do not always have to follow the pCT results, but rather rely on the CT scan.CT angiography of the cerebral and intracerebral arteries taken from the level of the aortic arch. The patient moved during the examination, because of this, the head is bent to the right and slightly upwards. Full occlusion of the right internal carotid artery is visible in its proximal part.MR Diffusion Weighted Imaging (DWI) and corresponding apparent diffusion coefficient (ADC) sequences. A. In the DWI sequence a large area with a hyperintense signal corresponding to cerebral ischemia is visible in the right hemisphere. B. In the ADC sequence the same area has a hypointense signal which may correspond, including DWI images, to the acute nature of ischemia.MR Fluid-attenuated inversion recovery (FLAIR) and DWI sequences. DWI-FLAIR-mismatch. No marked parenchymal hyperintensity is detected on fluid attenuated inversion recovery (FLAIR) images on right hemisphere (C), while acute ischemic lesion is clearly visible on DWI (D), indicating DWI-FLAIR-mismatch. Old post-stroke lesions are visible in the left hemisphere of the brain.Digital Subtraction Angiography—DSA. The distal end of the aspiration catheter through which a contrast agent is administered is inserted into the proximal segment of the right internal carotid artery. The place of the occlusion is visible through which the contrast agent does not flow.Rotary Digital Subtraction Angiography—3D DSA. Control examination performed directly after successful mechanical thrombectomy—mTICI 3. Visible flow of contrast blood both through the main trunk of the internal carotid artery and its branches.Two years ago, the patient had his first ischemic stroke of the left hemisphere of the brain, which left him with only slight neurological deficits—mRS 1. At the present admission to the hospital, he was confused and had full left limb paresis—NIHSS 16. The CT scan was started 2 h 20 min after the onset of the symptoms of the stroke. The film  on the basis of the observed clinical symptoms or individual assessment of the prognosis after endovascular procedures.Creating a pilot network with referring patients to a superior center (depending on the occlusion of large vessels detected in angioCT) as a reference center would allow avoiding local problems related to a shortage of specialist local staff, and facilitate a personalized approach, guaranteeing the comfort of work of all persons participating in the pilot project as it was done in Poland, like as in China .Incomplete formalized reimbursement services for the mechanical thrombectomy (related to the lack of dedicated procedures) are also a real problem, which, in the case of randomized trials, show that the use of EVT as an option for the treatment of acute ischemic stroke eliminates the costs associated with patient care during the first year of stroke and generates savings in the next years of the patient’s life ,48. In tThe presented problems related to delays in EVT concern many healthcare systems , thus liIn a randomized clinical trial to evaluate rapid EVT of ischemic stroke, quality control was highlighted as a guideline for ultimate success in the treatment of causative agents with weekly monitoring of imaging speed with feedback to central centers via teleconference . TraininOngoing efforts should aim to precisely define the occurrence of intracranial occlusion (LVO) in the transmitted available imaging test results (angioCT) with a precise estimation of the time needed to influence pre-hospital triage decisions in order to eliminate delays in causal treatment of individual patients. Successive efforts should focus on identifying real obstacles and problems guaranteeing the improvement of pre-hospital triage and the availability of pre- and post-processing IT systems, combined with timely monitoring of causal treatment of ischemic stroke and long-term care.Future efforts should also counter the importance of telemedicine facilitating the pre-registration process using devices with GPS navigation applications, which will further facilitate the proper selection of data based on real-time information with the possibility of verifying times: while driving with synchronization of the work time of the neuro-intervention team that will review current regimens and provide long-term health benefits in patient care for ischemic stroke induced by intracranial LVO.Intravenous thrombolysis with rt-PA and endovascular thrombectomy are the current standard of care for acute ischemic stroke ,51. Thei+/K+-ATPase activity, overload of cells with sodium, calcium [The pathophysiology of reperfusion injuries include: damage to the blood–brain barrier (BBB) , structu calcium , partial calcium ,59. Subs calcium . Ischemi calcium . As a co calcium ,63 and d calcium , which e calcium .Single results of clinical data in humans are inconclusive due to the occurrence of perifocal edema and leakage of the BBB by labeled metabolites, which complicate the interpretation of effectiveness of reperfusion procedures ,67. In aThe effectiveness of the reperfusion procedures used in ischemic stroke may be limited by the secondary ischemia-reperfusion injury of the brain, which may increase the volume of ischemia and aggravate the cerebral infarction ,72,73. TWith regard to the reperfusion procedures, the current efforts are focused on achieving complete reperfusion already during the first thrombectomy attempt as a favorable end result of EVT using mechanical thrombectomy and/or a strategy combining thrombectomy with thromboaspiration . NeverthIn the literature on the subject, attention was paid to the relationship between the appearance of the symptom of the so-called hyperdense middle cerebral artery sign of the brain shown in the CT scan in the acute phase of stroke with the size of Hounsfield units (HU), which are associated with the number of red blood cells and their parameters, i.e., hemoglobin and hematocrit . AccordiIn addition to thrombolytic activity in blood vessels, rt-PA seems to have a neuroprotective effect consisting in the suppression of oxidative stress during reperfusion, which is associated with increasing phosphorylation of 5’adenosine monophosphate-activated protein kinase, increasing glucose uptake in neurons and promoting mitochondrial ATP production .The knowledge of the physical properties of the clot, i.e., its density or permeability, may influence its successful removal with MT ,86. In a2+ ingress in excess of the buffer capacity leads to osmotic edema of the mitochondrial crest, release of NADH, cytochrome c and cytosolic double-stranded DNA (dsDNA) into the cytoplasm of astrocytes. This, in turn, triggers a cascade of events that lead to increased expression of various pro- and anti-apoptotic proteins by initiating inflammatory responses, GMP-AMP synthase , sequentially to cell apoptosis in the penumbra [Cellular mechanisms developing in neurons after reperfusion are still debated. The recanalization therapies in ischemic stroke, apart from their undoubtedly beneficial influence on the restoration of normal cerebral circulation, might also start cellular pathways causing ischemic-reperfusion neuronal death along with changes in the morphology and function of mitochondria with hemorrhage transformation of the tissue necrosis zone after ischemia  and the penumbra ,99.2− creating a much stronger oxidant ONOO−, which is highly reactive and is mainly responsible for the toxicity of NO in hypoxic brain tissues [The cycle of events entails the opening of large conduction channels in the inner mitochondrial membrane, known as the mitochondrial permeability transitional pores (MPTP). This, in turn, contributes to the unrestricted penetration of small solutes, disturbance of ion gradients and alteration of the mitochondrial membrane potential, what leads to impairment of oxidative–antioxidant pathways . The act tissues .In the literature, the oxidative stress induced by damage to the brain tissue was indirectly related to the markers and characteristic metabolic abnormalities, however, the actual dynamics of ROS has not been recorded in vivo so far.2+ increases secondary to glutamate excitotoxicity, which further inactivates contracted astrocyte mitochondria located near glutamate [The resulting oxidative and nitrosative stress induce iron-dependent ferroptosis, a non-apoptotic form of cell death consequently leading to mitochondrial contraction and switching their functions off in the area of neurovascular units  104,105105. In tlutamate , leadinglutamate .Research is currently under way to precisely define the role of mitochondria in response to the functioning of neurons, astrocytes, and glial cells in ischemic brain damage . The divThe role of mitochondria in astrocytes is now extensively studied, gaining importance in the emerging field of astroneurology, where small astrocytic mitochondria exhibit neuro-adaptive abilities in an oxygen- and glucose-deprived environment. Thus, astrocyte mitochondria guarantee the maintenance of balance by phagocytosing synapses, fragments of axonal and neuronal mitochondria, and damaged proteins . During Glutamate excitotoxicity related to, inter alia, changes in transport activity as well as altered expression of glutamate transporters, plays a key role in this process, as research shows that calcium activation of glutamate transport by astrocytes seems to be a causative factor affecting the inhibition of mitochondrial function ,114. MicThanks to these abilities, it is possible to regenerate these organelles and survive in conditions of exposure to environmental stress of ischemic areas of the brain, which is a promising target of therapy improving the clinical condition of patients after stroke and reperfusion procedures.cav-1 gene, which is a critical determinant of unsealing BBB during reperfusion [Currently conducted clinical trials and animal models indicate that stroke is a network of interactions within the central nervous system (CNS) . In the erfusion . Due to erfusion . Calproterfusion . In the erfusion ,123.The assessment of the amount of released neutrophils after a stroke is a prognostic factor for the severity of a stroke or the degree of bleeding complications. The assessment of an increased neutrophil/lymphocyte ratio is associated with poor neurological improvement after ischemic stroke, which is attributed to the neurotoxic role of neutrophils in the post-ischemic brain region .In general, clinical, imaging, and laboratory biomarkers are important in the assessment of the prognosis of AIS or reperfusion procedures. In predicting annual mortality after ischemia, a worse prognosis is for those with higher NIHSS values and higher carotid intimal and middle membrane thickness (cIMT), lower coagulation parameters, i.e., antithrombin levels, lower platelet count, protein C, and albumin concentration, lower HDL cholesterol, higher concentration of factor VIII, von Willebrand factor (vWF), higher absolute white blood cell count, higher concentrations of tumor necrosis factor α (TNF-α), interleukin 10, high sensitivity C-reactive protein (hsCRP), vascular cell adhesion molecule 1 (VCAM-1), apoB, LDL cholesterol, and triglycerides ,126. In The severity of inflammation associated with damage to the BBB after reperfusion procedures is associated with the risk of hemorrhagic transformation after ischemic stroke , being aThe brain and the immune system constitute functional neuro–humoral connectivity, therefore, the death of nerve cells in the course of acute stroke leads to the release of a number of humoral response factors causing local inflammation in the damaged brain . These f+ administration, ultimately inhibiting apoptotic neuronal death [A particular interesting field about acute stroke management is related to neuroprotective therapies. Some reports suggest a potential role of these therapies , althougal death .+/K+-ATPase, which maintain the energy metabolism at a constant level, are inhibited [Hopes related to neuroprotection are also created by hyperbaric oxygen (HBO) therapy, whose mechanism is associated with the inhibition of mitochondrial apoptosis and disturbances in energy metabolism of these structures . The admnhibited .The excessive release of glutamate has become the target of a therapy using checkpoints related to protein kinases regulating the signaling pathways of the N-methyl-D-aspartate (NMDA) receptor . These iPreventing neuronal death and, thus, reducing neurological damage are complex tasks that cannot be successfully solved by targeting individual mechanisms.One of the treatment strategies discussed in the literature would be the inhibition of TAK1 (transforming growth factor-β-activated kinase 1) in microglial cells in order to protect before stroke by inhibiting the death of neurons, e.g., through the pro-apoptotic JNK/c-Jun pathway. As demonstrated in the mouse MCAO/reperfusion model, TAK1 does not show any neuroprotective activity. Moreover, TAK1 activation was observed in post-ischemic neurons, linking its presence with the death of neuronal cells through many signaling pathways, e.g., JNK/c-Jun, p38 and NF-κB . To datePost-stroke regenerative therapies currently focus on improving neural plasticity to reverse the disturbances in the nervous structure and improve the functioning of the neural network both during recovery and in the long term.Stem cell-based therapies are of interest because of their neuro-regenerative potential to promote neurogenesis and protect surviving neurons. Bone marrow stem cells (BMSC) and mesenchymal stem cells (MSC) promote neurogenesis in preclinical models of intracerebral transplantation with immunomodulatory properties capable of suppressing inflammation following stroke and, potentially, improving recovery .Cell therapies based on protective cell phenotypes are also an interesting approach of improvement after reperfusion therapy in ischemic stroke patients. Polarized microglial cells or peripheral blood mononuclear cells are promising therapeutic strategies because of their pleiotropic effects, which, depending on the microenvironment and adaptation properties, determine the variable phenotypes of cells in response to brain injuries ,154. MicAn enhanced immune system response during ischemic stroke is the target of advanced immunotherapies of ischemic inflammatory cascade while extending the therapeutic time window  over conTargeting receptors or proteins of channels and enzymes  involved in microglia-dependent neuritis is a promising goal of therapy after recanalization procedures, especially in the treatment of secondary damage caused by cerebral ischemia  . This isSelection of endpoints is a significant problem in assessing the effectiveness of the applied recanalization procedures both in clinical and pre-clinical evaluation. This applies in particular to the confirmed scientific evidence on the effectiveness of new drugs, which would be classified in terms of not only survival or functional improvement expressed according to the modified Rankin Scale (mRS) as the main endpoint, but also other measurable scales for the obtained results, e.g., independent measurements of imaging or laboratory tests . ExampleThe search for a possible treatment of ischemic stroke has evolved from finding a relationship between selective molecular events controlling the known mechanism of action of selected individual stages of the ischemic cascade, such as the use of glutamate receptor-specific antagonists  to synergistic and pleiotropic therapies combining glutamate antagonists and GABA agonists , which pBased on our previous experience related to the search for objective biomarkers of schizophrenia, which is characterized by the complexity of clinical symptoms and endophenotypic differentiation, we can draw conclusions that one must look at a new perspective in the search for the prognosis and treatment of strokes related to the cascade of events . In the The ongoing efforts focused on a number of variables covering all cells of the nervous system, i.e., neurons, astrocytes, and cells that form the blood–brain barrier, are focused around translational medicine. From the laboratory table and in vitro research, it will take the changes at the level of preclinical and clinical research involving the human brain, setting a new horizon of thought presumably capable of predicting complex neurological functions.A limitation of this approach is the complex nature of the neurovascular units (NVU) that form networks of connections throughout the brain that cannot be linked to unicellular in vitro models. Studies show the isolated functions of individual types of NVU cells, ultimately causing many problems of an interpretative nature in relation to the functions performed in vivo ,165, in Single-cell models, despite a number of limitations in relation to in vivo models, are simple and repeatable, thus, it becomes possible to control potential candidates for neuroprotective drugs and to assess their protective effects against glial cells and the functioning of the blood–brain barrier.Studies on the circulation of mitochondria between astrocytes and neurons during ischemia/reperfusion provide evidence of potential new targets for stroke therapy to address mitochondrial-related energy failure. Initial preclinical studies related to the rescue of neurons through astrocytic mitochondria have shown the first spectacular results in this area .Despite the triumphant recanalization therapies, thrombolysis and thrombectomy in the treatment of ischemic stroke, currently perceived treatment will require a redefinition of basic concepts to recognize the differential susceptibility associated with the complexity of the neurovascular units that make up the brain networks, requiring a pleiotropic approach to work through many different mechanisms of action.