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Stroke
is the third leading cause of death and the leading cause of disability
in the United States. More than 500,000 Americans suffer a stroke
each year; of these nearly 20% will die within a year. Persons
surviving a stroke often end up financially impoverished and socially
isolated, losing the ability to walk, talk or care for themselves.
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Stroke
is a disease that affects the blood vessels supplying blood to
the brain. It is also sometimes called brain attack. Blood containing
oxygen and nutrients is delivered to the brain via 4 arteries
and their branches: left and right internal carotid arteries;
left and right vertebral arteries. The two vertebral arteries
join together in the brainstem to form the basilar artery.
When
deprived of oxygen, nerve cells in the affected area of the brain
can't function and die within minutes. When nerve cells can't
function, the part of the body controlled by these cells can't
function either. The devastating effects of stroke are often permanent.
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What
are the different types of stroke?
A
stroke occurs when blood flow (and thus oxygen delivery) to
a certain part of the brain is interrupted. This can occur
by two mechanisms:
-
Ischemic
stroke can happen when a blood vessel in the brain is clogged
by a blood clot or some other particle. Because of blockage
part of the brain doesn't receive the blood it needs. Deprived
of oxygen (ischemia), affected brain
cells can't function and die within minutes. When brain
cells can't function, the part of the body controlled by
these cells can't function either. Stroke effects are often
permanent because dead brain cells aren't replaced.
-
Hemorrhagic
stroke is caused by a ruptured (burst) brain blood vessel.
When hemorrhage occurs, the loss of a constant blood supply
means some brain cells can no longer function. Another problem
is that accumulated blood from the burst artery may put
pressure on surrounding brain tissue and interfere with
how the brain functions. Severe or mild symptoms can result,
depending on the amount of pressure.
Approximately
80-85% of strokes are ischemic in nature while 15-20% are due
to hemorrhage.
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Ischemic
stroke is divided into 3 main categories:
- Thrombotic
strokes occur when a clot (thrombus)
forms within a brain blood vessel and blocks blood flow to that
area of the brain. Clots are more likely to form on the inside
of a brain artery that is injured or narrowed. Atherosclerosis
is by far the most common cause of thrombotic stroke in the
United States. Much less frequent causes may include dissection,
vasculitis, conditions that cause blood to clot too easily.
Thrombotic strokes cause about 70-80% of ishemic strokes (about
60% of all strokes).
- Embolic
strokes occur when a blood clot breaks loose in some other
part of the body, such as the heart, travels to and lodges in
a brain artery. Most embolic strokes originate from the heart,
aorta,carotid or vertebral arteries. Conditions such as atrial
fibrillation or valvular heart disease increase the risk
of emboli. Embolic strokes account for about 15-20% of all strokes.
- Systemic
hypoperfusion, occurring during a severe heart attack,heart
arrhythmias or extreme blood loss, is failure
of the heart to pump enough blood to the brain and can cause
stroke. Hypoperfusion is less common than thrombosis or embolism
as a cause of stroke.
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Hemorrhagic
Stroke is divided into 2 categories:
- Intracerebral
hemorrhage (ICH) accounts for about two thirds of hemorrhagic
strokes (10-15% of all strokes). Bleeding occurs directly into
the brain tissue, usually from small arteries (arterioles).
Most ICH are associated with chronic high blood pressure.
- Subarachnoid
hemorrhage (SAH) occurs when a blood vessel on the surface
of the brain ruptures and bleeds into the space between the
brain and the skull (but not into the brain itself). SAH is
usually due to an aneurysm in the brain.
Aneurysms
are blood-filled pouches that balloon out from weak spots in
the artery wall. They're often caused or aggravated by high
blood pressure. Aneurysms aren't always dangerous, but if one
bursts in the brain, a stroke results.
Brain
aneurysms (called berry aneurysms) usually occur at points where
the brain arteries branch or are just about to enter brain tissue
in an area known as the subarachnoid space.
Rupture in this area is often very serious because the blood
pressure is higher in this area than in smaller arteries that
have already entered the brain tissue.
SAH
occurs half as frequently as ICH. Ruptured subarachnoid aneurysms
cause about 10% of all strokes but cause a higher percent of strokes
in younger people (under 40 years).
They're often caused or aggravated by high blood pressure but
may occur in young otherwise healthy people.
Cerebral
and subarachnoid hemorrhages have
a much higher fatality rate than strokes caused by clots. The
amount of bleeding determines the severity of cerebral hemorrhages.
In 50 percent of the cases, people with cerebral hemorrhages die
within the first month due to increased pressure on their brains.
Those who live, however, tend to recover much more than those
who've had strokes caused by a clot.
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What
are risk factors for having a stroke?
Risk
factors are things that increase the chance of having a stroke.
Certain risk factors are important contributors to all types of
strokes while other factors may favor a specific type of stroke.
Secondary
risk factors that indirectly increase the risk of stroke by
increasing the risk of heart disease include:
- High
cholesterol
- Lack
of exercise
- Obesity
Other
factors affecting the risk of stroke
- Geographic
location - Strokes are more common in the southeastern United
States than in other areas.
- Season
and climate - Stroke deaths occur more often during extremes
(hot or cold) of temperature.
- Excessive
alcohol intake - Excessive drinking ( average of greater
than one drink per day for women and more than two drinks per
day for men) and binge drinking can indirectly lead to a stroke
by raising blood pressure, contributing to obesity, and causing
heart failure.
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What
are symptoms of a stroke?
Strokes
affect different people in different ways depending on the type
of stroke, the part of the brain affected and the amount of the
brain injury. Stroke symptoms may include:
- Sudden
numbness or weakness of face, arm or leg, especially on one
side of the body.
- Sudden
confusion, trouble speaking or understanding speech.
- Sudden
trouble seeing in one or both eyes.
- Sudden
trouble walking, dizziness, loss of balance or coordination.
- Sudden,
severe headache with no known cause. Often described as "feeling
like my head is going to explode" or the worst headache
of my life.
It
is often not possible to tell what type of stroke (bleeding,
thrombotic, or embolic) is occurring based on the symptoms a
person is having.
Bleeding
strokes are more likely to occur in younger people (under
40 years), be preceded by severe headaches and cause decreased
consciousness or coma.
Embolic
strokes are more likely in persons with existing heart
valve disease, congenital heart defects, atrial
fibrillation and other heart arrhythmias.
Thrombotic
strokes are more likely in persons with known narrowing
of neck or brain arteries (carotid artery stenosis) and prior
stroke or TIA's with the similar symptoms.
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What
is a TIA or transient ischemic attack?
If
blood flow is restored quickly any of the above signs may be only
temporary and last from a few minutes upto half an hour. This
may be due to a "little stroke" or "mini-stroke" called a transient
ischemic attack or TIA
About
10 percent of strokes are preceded by TIA's. About a third of
people who have had one or more TIA's will later have a stroke.
A person who has had one or more TIA's is almost 10 times more
likely to have a stroke than someone of the same age and sex who
has not. Increasing frequency of TIA's may indicate an impending
stroke. See your doctor immediately if TIA's are occurring more
frequently.
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What
to do if having stroke symptoms!
 |
IF
YOU NOTICE ONE OR MORE OF THESE SIGNS, DON'T WAIT!
CALL YOUR EMERGENCY MEDICAL SERVICES.
GET TO A HOSPITAL RIGHT AWAY!
|
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How
is a stroke diagnosed?
At
the hospital, the emergency department staff or your doctor will
check to see if you are having a stroke by:
-
Asking you about your symptoms;
- Testing
the muscles of your body for strength, coordination and sensation.
- Performing
a CT scan to determine what type of stroke
you might be having;
- Taking
a blood samples to test for red blood cell count, blood sugar,
electrolyte concentration, and how your blood clotting system
works.
- Perform
an EKG to see if a heart problem might be causing a stoke.
These
tests should be performed as quickly as possible so optimal stroke
treatment may be given.
If
the emergency department staff suspects you are having a stroke
they will hook you up to a heart monitor, place a catheter(s)
in your vein(s), and give you additional oxygen through a tube
attached under your nose.
Symptoms
Your
doctor will want to know how long symptoms have been present
and whether or not you have had a previous stroke or similar
symptoms. If symptoms have been brief (less than several hours)
and your stroke is not due to bleeding (hemorrhage) in the brain,
clot dissolving medicine may be considered. Your doctor will
want to know if you have a severe headache.
Physical
exam
Strokes
may produce certain patterns depending on the part of the brain
involved. Knowing the severity of stroke symptoms is very important
in deciding how aggressively to treat the stroke because certain
treatments have serious side effects.
For
example, treating a severely disabling ischemic stroke in an
otherwise healthy person with a clot dissolving medication would
likely be worth the increased risk of severe brain hemorrhage
associated with the use of this medication. However, in a patient
having a mild stroke with relatively little disability the risk
of severe brain hemorrhage would outweigh possible mild benefits
gained from use of clot dissolving medication.
CT
scan the most important test in majority of stroke patients
because it can accurately tell whether or not a stroke is due
to bleeding in the brain.
- Should
be performed in all patients suspected of having a stroke.
- CT
scan does not detect most ischemic strokes for at least 6
hours. However, it is excellent at detecting bleeding in the
brain from hemorrhagic (burst blood vessel)strokes.
It
is extremely important to determine what type of stroke (hemorrhagic
or ischemic) you are having because treatment is different for
each type. Blood thinners or clot dissolving medications used
in ischemic strokes will make a hemorrhagic stroke worse!
Lab
tests
EKG
- Atrial
fibrillation and heart attack cause a majority of embolic
strokes. If either are detected on EKG it is much more likely
that a stroke is from heart emboli. Treating the underlying
heart problem will be important in both treatment and future
stroke prevention.
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Stroke
Treatment
Surgery,
drugs, acute hospital care and rehabilitation are all accepted
ways to treat stroke. Treatment will depend on both type and severity
of stroke. When a neck artery has become partially blocked, surgery
might be used to remove the buildup of atherosclerotic plaque.
This is called carotid endarterectomy . Cerebral
angioplasty is a new experimental technique. Balloons, stents
and coils are used to treat some types of brain blood vessel problems.
Widespread use of these experimental techniques will require further
study of safety and effectiveness.
Initial
treatment of ischemic (thrombotic and embolic) strokes
Thrombotic
and embolic strokes are due to blockage of
blood flow from blood clots. Once it has been determined that
a person is not having a bleeding stroke they may be given anticoagulant
(blood thinning) or thrombolytic (clot dissolving)
medications. These medications may include aspirin, heparin,
or tissue plasminogen activator (TPA).
Aspirin
Low
dose aspirin (1-4 baby aspirin) are given to almost all patients
suffering from a nonbleeding stroke. Aspirin prevents platelets
(part of the blood clotting system) from sticking together.
Aspirin may decrease the severity of stroke and definitely decreases
the risk of having another stroke. Aspirin is very safe for
people not allergic to it.
Anticoagulants
Anticoagulant (blood thinners) work by preventing certain blood
clotting factors from working. Anticoagulants prevent new clots
from forming but do not dissolve preexisting clots. Use of anticoagulants
increases the risk of internal bleeding. There are two anticoagulants
used in stroke patients.
Heparin
is given intravenously for the first 3- 5 days for certain
stroke patients. Heparin works very quickly and its blood
thinning effects stop a few hours after being discontinued.
Coumadin
is taken by mouth once a day and may be started the second
or third day after a stroke. Coumadin takes several days to
become effective. Heparin is stopped once the desired level
of blood thinning with coumadin has been reached. Certain
blood tests can tell how well both heparin and coumadin are
working.
Anticoagulants
are indicated for embolic stroke, particularly
emboli arising from the heart. Heparin is still used by many
doctors for all cases of ischemic stroke. It is unclear whether
it actually improves stroke outcome for thrombotic strokes.
It is sometimes difficult to determine whether an ischemic stroke
is thrombotic or embolic. There is an increased risk (about
1%) of converting an ischemic stroke into a bleeding stroke
with the use of heparin. This is bad because bleeding strokes
have a 30-50% death rate while that of nonbleeding (ischemic)
strokes is 10-15%.
Long term use of coumadin has not been shown to be any more
effective than aspirin in preventing recurrent stroke in patients
not having emboli.
Thrombolytics
(clot dissolvers)
Tissue
plasminogen factor (TPA) is a clot dissolving medicine that
has been used for some time in persons having heart attacks
and recently approved by the Food and Drug Administration (F.D.A.)
for stroke treatment. It has recently shown great promise in
treatment of ischemic stroke. Studies have shown that persons
receiving TPA are more likely to have improved outcome than
those not receiving TPA.
TPA
must be used carefully and is not for all patients.
- TPA
may be indicated for patients having ischemic (thrombotic
or embolic) stroke who seek treatment within 3 hours of the
onset of symptoms.
- A
CT scan must be performed to exclude brain bleeding.
- TPA
can not be used in persons with bleeding strokes, recent major
surgery, extremely high blood pressure or in people taking
coumadin.
Use
of TPA increases the chance of converting an ischemic stroke
into a bleeding stroke from 0.6% to 6%( 10 times) even when
patients with contraindications are excluded from receiving
TPA. About 50% of persons with TPA induced bleed will die or
be severely disabled.
It
is our opinion persons receiving TPA must fully understand the
risks as well as benefits. For example, a person having a mild
stroke with minimal loss of function must weigh the relative
benefits versus the very real risk (1 in 18) of sustaining a
much more severe stroke with TPA. This is a highly personal
choice. A person's age, health and prior level of activity are
all considerations.
Long
term treatment (prevention) of ischemic strokes
The
goal of long term treatment is to prevent either an initial or
recurrent stroke. Type of treatment will depend on underlying
cause.
Aspirin
Use of low dose aspirin on a daily basis has been shown to significantly
decrease the frequency of TIA's and the likelihood of all types
of ischemic stroke.
Anticoagulants
Long
term use of coumadin after stroke has been replaced by aspirin
use for most patients. Coumadin is still used in persons at
high risk of recurrent embolic stroke. Risk factors include
atrial fibrillation, valvular or congenital
heart disease.
Surgery
Narrowing
of the carotid artery (neck artery) may cause wither TIA's or
thrombotic stroke. When the carotid artery is narrowed more
than 70-75% a surgical procedure, called carotid
endarterecomy, has been shown to greatly decrease the risk
of stroke due to carotid artery thrombus. If narrowing is less
severe such surgery has not been shown to decrease stroke risk.
Initial
treatment of hemorrhagic stroke
Management
of hemorrhagic strokes is complex. Hemorrhagic strokes are associated
with higher rates of death than ischemic strokes. Most intracerebral
bleeds (ICB) are left alone. Accumulated blood from the burst
artery puts pressure on surrounding brain tissue and interferes
with how the brain functions. Severe or mild symptoms can result,
depending on the amount of pressure. Surgery may be done persons
with large bleeds who are alert but deteriorating. Doctors will
gently lower extremely high blood pressure with medications.
Subarachnoid
hemorrhages have the highest risk of rebleeding in the first 24
hours. In hospital management includes carefully controlling blood
pressure and using certain medications that reduce spasm of brain
arteries after hemorrhage has occurred. Angiography is usually
performed to see where bleeding is coming from. In certain cases
surgery may be done to "clip" the leaking blood vessel
shut.
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Stroke
effects
- Emotions
- A stroke survivor may cry easily, often for no apparent reason.
This is called emotional lability . Laughing uncontrollably
may also occur but is not as common as crying. Depression is
common, as people who have experienced stroke may feel less
than "whole".
- Depression-
is very common after stroke. It more likely in persons living
alone and in those having speech/ communication impairment.
Your doctor may prescribe low dose antidepressants to help with
depression.
- Bodily
awareness- Stroke often causes people to lose mobility and/or
feeling in an arm and/or leg, or suffer dimness of sight on
one side. The loss of feeling or vision may result in a loss
of awareness. Stroke survivors may forget or ignore their weaker
side. This problem is called "neglect." As a result, they may
ignore items put on their affected side, have trouble reading,
or dress only one side of their bodies and think they're completely
dressed. Bumping into furniture or door jambs is also common.
One-side neglect is most common in those with injury to the
right side of the brain.
- Perception
- A stroke can also affect seeing, touching, moving and
thinking, so a person's perception of everyday objects may be
changed. Stroke survivors may not be able to recognize and understand
familiar objects the way they did before. When vision is affected,
objects may look closer or farther away than they really are,
causing spills at the table or collisions when walking.
- Speech
- Usually stroke doesn't cause hearing loss, although people
may have problems understanding speech. They also may have trouble
saying what they're thinking. This is called aphasia.
It is most common when a stroke weakens the right side of the
body (effects the left side of the brain).
A
related problem is that a stroke can affect muscles used in
talking (those in the tongue, palate and lips), and speech
can be slowed, slurred or distorted. Stroke survivors thus
can be hard to understand. This is called dysarthria
and may require the help of a speech expert.
- Swallowing
- Stroke can affect chewing and swallowing food. The mouth
muscles may be weak, lack feeling or the normally protective
gag reflex may be absent. Swallowing difficulty is called dysphagia
and increases the risk of choking and inhaling mouth contents
into the lungs.
- Thinking
- Stroke can affect the ability to think clearly. Planning and
doing simple activities may be hard. Stroke survivors may not
know how to start a task, confuse the sequence of logical steps
in tasks, or forget how to do tasks they've done many times
before.
- Movement-
Stroke can affect the ability to use an arm and/ or leg. This
usually occurs on one side of the body. Walking, dressing, or
getting on or off the toilet may be difficult or impossible.
- Bladder-
About half of stroke patients have bladder control problems
the first several weeks. For a vast majority of patients this
improves without treatment.
- Muscle
Pain often occurs for a variety of reasons. It may be from
rehabilitation exercises that are too vigorous, in persons who
are not active enough, in muscles that are spastic or in persons
who have been tugged on to help them up. Nonsteroidal anti-inflammatory
medications, muscle relaxants, local anesthetics, or cortisone-like
medications may be prescribed.
- Sexual
Dysfunction- Sexual desire remains intact in most people
after a stroke! However, many men and women who were previously
sexually active experience problems with sexual performance
because of physical and/ or psychological difficulties. Physical
reasons include decreased movement, pain and medication side
effects. Many persons, or their partners, may be inhibited by
fear that sex may cause another stroke or the misperception
they should not be having sex. This is a myth! Treatment may
include counseling, exploration of different sexual techniques,
and/ or use of medications (in men without heart problems) for
erection.
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Recovery
after a stroke
Stroke recovery is often the most difficult part for many persons.
Stroke can turn independently living persons into disabled ones
dependent on others for help. How well a person recovers after
a stroke will depend on a number of factors including the type
of stroke, severity of stroke, area of the brain effected by the
stroke, overall age / health before the stroke, and available
family/ social support after a stroke. Most stroke patients (about
70%) are eventually able to perform basic activities and take
care of themselves; however, many of these do not have the same
level of social interaction they had before the stroke.
Prognosis
for recovery
Persons
with mild speech or mobility problems generally do better
and recover more quickly than those with moderate to severe
deficits. Improvement,usually most noticeable in the first
6 weeks, may continue for upto one year.
During
a stroke there is often a zone surrounding the area of brain
effected that is injured but does not die due to collateral
circulation. This area often regains function over time.
In addition, other parts of the brain may attempt to do the
job of the area that was lost: specialized cells (called glial
cells) to "rewire" various brain cells and parts
of the brain.
Early
rehabilitation goals
The
primary care doctor has an important role in early stroke rehabilitation
by recognizing, preventing , and treating other medical problems
that may worsen a person's health, make recovery more difficult,
and make another stroke more likely. This includes paying attention
to blood pressure, nutrition, bladder function, blood sugar
levels, proper use of medications such as aspirin and anticoagulants,
and safety during self-care tasks.
Long
term rehabilitation goals
The
long term goal of stroke rehabilitation
is to decrease disability and handicap.
Physical therapists work with patients to improve ability
to move and self-care. This includes working with large muscle
groups involved in walking, dressing and being able to use
a toilet. Occupational therapists focus on integrating muscle
movement (coordination), particularly the hands and arms,
into purposeful function. They work with patients using assistive
devices for daily activities. Speech therapists help with
swallowing and language impairments. Social workers, neuropsychologists,
orthotists, dietitians and bioengineers may also be involved
in after stroke care
-
While
still in the hospital persons who have had a stroke should
have physical therapy, occupational therapy, and speech /
swallowing evaluations to determine the appropriate level
of support and rehabilitation they may require. This evaluation
typically occurs 2-3 days after a stroke. Typical hospital
stay after an uncomplicated stroke is 1-2 weeks.
-
Persons with limited disability and excellent family support
are often able to go home and receive outpatient rehabilitation
services.
-
Persons
with moderate to severe disability ( may not be able to walk
and have trouble speaking) may be considered for admission
to an inpatient stroke rehabilitation center. Many studies
have shown that persons with moderate impairment receiving
care in specialized stroke recovery centers have improved
recovery and survival compared to those receiving rehabilitative
care in a general medical ward.
-
Elderly
persons with significant disability (bedridden, having severe
dementia, etc..) are usually transferred
to a nursing home. Nursing homes are able to provide rehabilitation
services.
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Can
strokes be prevented?
Although
not all strokes can be prevented the chance of having one can
be reduced for most people. Risk factors
were previously listed. Treatable factors include:
-
Controlling blood pressure and not smoking are the two most
important things most people can do to decrease their risk of
stroke.
- If
you are diabetic controlling blood sugar and regular modest
exercise will be important.
- Lowering
cholesterol decreases the risk of heart disease and stroke in
persons with high cholesterol. This may be accomplished with
diet, exercise, and/ or medication.
- Daily
aspirin has been shown to decrease the risk of both ischemic
stroke and heart attack.
- Persons
with valvular heart problems or certain types of irregular heart
beats, particularly atrial fibrillation,
should be on anticoagulants.
It
is important for a person to see their primary care doctor for
regular health checkups.
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| Aphasia |
injury
to the language processing center in the brain impairing
the ability to talk, listen, read and write or understand
speech. |
| Arrhythmia |
an
irregular heart rate. There are many different types
of arrhythmias |
| Atherosclerosis |
narrowing
(stenosis) and stiffening of an artery due to build
up of fatty deposits and calcium inside an artery. |
| Atrial
fibrillation |
rapid
uncontrolled quivering of the upper chambers (atria)
of the heart. The atria do not effectively pump blood. |
| Carotid
endarterecomy |
carotid
artery surgically opened and the atherslerotic plaque
(blockage) is removed. The artery is then sewn closed. |
| Cerebral
angioplasty |
a
very fine balloon tipped catheter is threaded through
an artery to the blockage. The balloon is inflated
to expand the blocked artery. |
| Collateral
circulation |
increased
blood flow in small blood vessels indirectly supplying
blood to a region of the brain when the blood flow
from a main artery to the region is blocked. |
| Congenital |
An
abnormality occurring before birth. Can be caused
by infection, medications, chemical, radiation exposure,
or genetic factors. |
| CT
(CAT) scan |
Computerized axial tomography uses a series of x-rays
and computer to generate an image of the brain. |
| Dementia |
impairment
of a person's ability to remember past events, be
aware of current events in their life, or think in
an organized and logical manner. |
| Disability |
is
limitation in activity due to physical or emotional
impairments. An example would be a person who has
had a stroke paralyzing one leg or arm not being able
to walk across a room without assistance or type on
a keyboard. |
| Dysarthria |
difficulty
speaking clearly (slurred speech) due to weakness
of tongue and mouth muscles. Language understanding
often normal |
| Dysphagia |
difficulty
swallowing |
| Embolus |
a
clot (thrombus) that breaks loose from where it is
formed and travels via the bloodstream to and lodges
in another part of the body. |
| Handicap |
is
a limitation on participation in an activity
or performance of a usual role. An example would be
a person unable to walk not being able to climb up
the stairs of a building to get to their job if an
elevator was not available |
| Hemorrhagic |
severe
bleeding |
| Heparin |
an
anticoagulant (blood thinner) that prevents new blood
clots from forming or ones already present from getting
bigger. Does not dissolve clots already present. |
| Ischemia |
lack
of sufficient oxygen to an organ or cell. Usually
caused by blocked blood flow. Prolonged ischemia causes
death of a cell, organ or person. |
| Rehabilitation |
after-stroke
treatment attempting to improve a person's level of
functioning to what it was before the stroke. |
| Subarachnoid
space |
a
space between the inside of the skull and brain surface
that is filled with cerebral spinal fluid. |
| Thrombolytic |
clot
dissolving medication such as TPA |
| Thrombus |
a
blood clot or other material causing blockage at the
place it forms (versus an embolus that travels from
where it was formed). |
| TPA |
tissue
plasminogen activator is a medication that can dissolve
blood clots that have already formed. |
|
Top
Other
Sources of Information
|
American
Heart Association
American
Stroke Association
American
Academy of Family Practice
Dobkin, B. H., Disabling Stroke: Managing common symptoms
in FAMILY PRACTICE RECERTIFICATION, (vol. 21, #12, October
1999).
Dobkin,
B. H., Disabling Stroke: Setting rehabilitation goals
in FAMILY PRACTICE RECERTIFICATION, (vol. 21, #12, October
1999).
|
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Doctors
Corner INternet Group, Inc. 1997-2004
|
