Causes, types, symptoms and consequences of stroke

Strokes are characterized by a variety of causes the disease. It is proved that the etiology of stroke in women and men in some cases different. Causes of stroke women mostly lie in the plane of the pathophysiology of the fertile period and menopause, in men, they are usually due to occupational risks and harmful habits. These same characteristics are associated differences of pathogenesis and the effects of stroke gender groups.

What is a stroke?

• Hemorrhagic stroke – bleeding (hemorrhage) in the brain tissue;
• Ischemic stroke – the area of infarction (necrosis) in the tissues of the brain.

These signs detect by CT, MRI, EEG. link

Symptoms of brain or focal brain lesions, obtained the publicly available methods are not always the result of a stroke. The work on the classification of vascular lesions of the brain began in 1971, E. N. Schmidt, in the final version proposed in 1985.

Signs of stroke in women and men

The signs of a stroke is a subjective (personal) feeling of a person or objective (obvious) description of the diseases of a bystander, which is the reason for the treatment of the sick for help in a medical facility.

The signs of a stroke should know of all people, regardless of medical education. These symptoms are primarily associated with the violation of innervation of the muscles of the head and body, so if you suspect a stroke, ask the person to perform three simple actions: smile, raise hands, say any word or sentence.

If a person has a stroke, this simple test will show the following results:

• The smile looks unnatural, the corners of the lips are located on different lines, which is associated with the limitation or complete inability of the contraction of the facial muscles;
• The show of hands looks like a steel action arm on the affected side has no power, that is spontaneously lowered, the handshake is weak;
• The pronunciation of the words or phrases in the form of paresis or paralysis of facial muscles difficulty.

There are other similar tests. Unfortunately, identifying signs of a stroke means the statement (confirmation) of the beginning of irreversible effectsin the brain. The faster the qualified help to the patient, the greater the chance of treating the consequences of stroke.

The symptoms of certain types of stroke (ischemic) is manifested before the development of changes in the tissues of the brain. Such symptoms are called initial manifestations of insufficient blood supply to the brain (NPNKM), they are transitory (passing) ischemic attack or hypertensive crisis. Their timely identification is recommended for prevention of development of clinical forms of stroke.

NPNKM easy to identify at home with the help of a questionnaire HP manvelova. One positive response (+) is equal to one point. To confirm the diagnosis should be at least twice reply (+) to questions about the presence at least once a week or constantly for the last three months of the following sensations:

• Headache without clear localization, not due to hypertension, often associated with fatigue and weather change: (+) or (-);

• Dizziness, aggravated by changing body position in space: (+) or (-);
• Noise in the head, permanent or transient: (+) or (-);
• Impaired memory, which covers current events, logical memory, as a rule, does not suffer: (+) or (-);
• Sleep disturbance and/or health: (+) or (-).

If the subject scored more than two points – this means that it has the prerequisites of swift development of stroke. You should refer to our General practitioner to get a referral to a neurologist for laboratory and instrumental examinations and treatment.

A stroke is not always visible to outsiders signs. Sometimes they are obvious only on the basis of personal experiences when performing common tasks, for example, characteristic only for women or only for men.

First aid at the first sign of stroke

After identifying signs of a stroke you must do the following:

1. To call an ambulance, call free:

   • call from a landline 03;
   • call from mobile phone 112 or 03*.

2. The patient to take a horizontal position on the bed, his head slightly above the body:

   • if you have dental prostheses, eye lenses, glasses remove;
   • if the patient is unconscious –to help him her mouth half open, his head slightly tilted to one side, to follow the breath.

3. Before the arrival of the ambulance:

   • to record the names, dosage and frequency of medications the patient is taking;
   • to record the names of unbearable sick of drugs (if any);
   • to prepare the passport, medical insurance, patient file, if it is the patient.

4. Inform the emergency room physician known information about the patient.

5. Possible accompany the patient to the emergency room of a hospital.

A patient in the hospital is according to the standards of medical care in stroke patients, approved by Order of the health Ministry of the Russian Federation No. 513 from 01.08.2007.

Temperature in stroke

The number of scientific publications testifies to the negative influence of high temperature on the outcome of stroke. At the same time, reports on the use of low temperature (hypothermia and normothermia) in neuroprotection of brain cells during therapy of disorders of cerebral krovoobraschenie.

The pathogenesis of stroke is largely determined by the status of the thermoregulation of a patient. One of the causes of coma the patient with stroke – a violation of thermoregulation.

Hyperthermia is diagnosed in 40-70% of patients with hemorrhagic stroke and 18-60% with ischemic stroke.

• The leading cause of hyperthermia in stroke – purulent-inflammatory processes in the body, which developed as a complication of pneumonia, urinary tract infection, bedsores.

• The second reason is hyperthermia – supratentorial brain tumors. Temperature when they are not independent from purulent processes in the body.

The method of hypothermia with the goal of preserving structures of the brain damaged by a stroke, was widely used until 70-80 years of the last century. From the perspective of the method declined due to many complications. Currently, with the opening of new means and methods in biology and medicine, the use of hypothermia in stroke is again widely discussed, with the aim of neuroprotection from neuronal cascade of pathological reactions in the brain when a stroke in the first stage.

Classification and types of stroke:

Types of stroke: Ischemic stroke Hemorrhagic stroke A massive stroke Lacunar stroke (LEE) Spinal stroke Acute stroke A minor stroke Re stroke

Ischemic stroke

Ischemic stroke (AI) – the most common form of stroke. According to various estimates, up to 80% of all strokes are ischemic. AI has a different name – cerebral infarction, that is, the focus of necrosis formed on the periphery of the phase delays of blood flow. Necrosis in AI is the result of violations of metabolism in the cells of the brain with the phenomena of stagnation of blood at the site of the nervous tissue.

Causes of stagnation of blood in the blood vessels, neuronal and glial brain tissue:

• Stenosis (narrowing) or occlusion (blockage) of large arterial vessels of the brain;
• Thrombosis – blockage of a blood vessel by a blood clot (thrombus – a clot of blood cells);

• Embolism – blockage of a blood vessel by an embolus (an embolus is a clot of fat cells, which normally there is no in the blood stream).

Hemorrhagic stroke

Hemorrhagic stroke (GI) the most dangerous form of stroke. According to various sources, death of GI is up to 82% of cases. GI is the result of the rupture of a blood vessel and education in the location of the clot and further the area of necrosis. More severe pathogenesis of GI in comparison with AI is due to the development focus of hemorrhagic stroke and layering of ischemia.

The development of hemorrhagic stroke in the first stage occurs in the following sequence:

1. Hematoma causes direct mechanical compression of brain tissue,

2. The formation in this phase of the ischemic zone;

3. Hematoma and ischemia around her starts the cascade of pathogenic processes.

The hematoma volume when GI is several times less extensive ischemia around the hearth of hemorrhagic stroke.

A massive stroke

A massive stroke is the generic name of massive strokes. Classification of acute cerebral ischemia (E. I. Gusev, 1962) OI corresponds to severe strokes with pronounced cerebral symptoms:

• Oppression of consciousness;
• Swelling of the brain;
• Hemiparesis or hemiplegia of the opposite side of the lesion;
• Paresis of gaze toward the paralyzed limbs;
• Disorder of consciousness in the form of hemispheric damage (aphasia – a speech disorder, Geminate – loss of half the field of view, anosognosia – lack of understanding of patientof your condition);
• Vegetative disorders – disorders of the nervous regulation of internal organs and body systems.
• Trophic disorders – disorders of nerve conduction, which are manifested by skin ulcers.

Massive stroke complicated by secondary stem syndrome in disorders of consciousness and oculomotor disorders:

• Anisocoria – changes the size of the pupil, it is increased on the side of the affected hemisphere;
• Ophthalmoplegia – the weakening or absence of reaction of pupils to light;
• Strabismus and strobizm (pendulum movements of the eyeballs);
• Garmatnij generalized disorders in the form of muscle tonic spasm of muscles;
• Decerebration rigidity – increased muscle tone of extensors,

Localization broad strokes correspond to lesions in the basins of major precerebral and cerebral arteries (classification E. V. Schmidt, 1985, and ICD-10).

Data on comparison of frequency of occurrence of broad strokes in men or women is not found. Broad strokes are a common cause of death in patients or long-term (lifelong) disability.

Lacunar stroke (LEE)

Lacunar stroke is a type of ischemic brain infarction. WHETHER characterized by limited involvement of one of the small perforating arteries. The perforating arteries are small vessels with a size from a fraction up to 2 mm, with a length of 10 cm, between the larger deep and superficial arteries. The name "lacunar stroke" obtained in connection with the formation at the site of infarct cavities (lacunae) round shape (diameter less than 1.5 cm), filled with liquid – the cerebrospinal fluid.

The incidence (occurrence) lacunar stroke on average 20% of all ischemic strokes. They are not characteristic of cerebral and meningeal symptoms.

Lacunar stroke detected by the focal symptoms:

• Ataxic hemiparesis – inability of half of the body;
• Dysarthria – violation of the clear pronunciation of the words;
• Monoparesis – impaired motor activity of the arms or legs.

From the group of patients with a diagnosis of lacunar stroke women account for approximately 54% and men 46%. The average age of patients with a diagnosis of LI: from 48 to 73 years.

The most common cause of lacunar stroke – atherosclerosis on the background of arterialhypertension. It has also been proven embolic nature WHETHER, in this case the disease is for patients harder due to the involvement in the pathogenesis of a larger area of the brain after occlusion of vessel by embolus. Forecast lacunar stroke depends on the localization and time of initiation of treatment.

Spinal stroke

Spinal stroke – is an acute violation of blood circulation in the spinal cord. Causes of spinal stroke may be ischemic or hemorrhagic stroke of the brain. The usual place of localization of spinal stroke in the major arteries of the cervical and lumbar enlargement or the fine branches of the reticulo-medullary arteries.

SI is more common in older people. Differences in the pathogenesis of spinal strokes in men and women is not revealed.

Accurate data on the prevalence of spinal strokes no. This is probably due to the difficulty of differential diagnosis. More accurate diagnosis became possible after wide introduction of CT, MRI and selective spinal angiography.

Some sources indicate the next harbingers of a spinal stroke.

• Radicular syndrome – the pain of different localization (neck, arms, legs, lower back);
• Chronic vascular cerebrospinal insufficiency (HSMN);
• Periodic severe headaches;
• Noise and heaviness in the head;
• Momentary vertigo;
• Fatigue and sleep disorder;
• Memory impairment;
• Syndrome myelogenous intermittent claudication – numbness in the feet during long walks with rapid disappearance after rest, pain in the legs is missing.

The clinical picture of SI is varied, it depends on the location of localization of stroke in the spinal column.

Ten spinal ischemic syndromes:

• The ventral half of the spinal cord or occlusion of the anterior spinal artery syndrome or Transfiguration;
• Front poliomyelite;
• Broun-Sekar;
• Centralcollege stenosis;
• Regional zones of the front and side ropes;
• Amyotrophic lateral sclerosis;
• The dorsal part of the spinal cord diameter (syndrome Williamson);
• The spinal cord diameter;
• Occlusion of the artery of the cervical enlargement;
• Off artery of the lumbar enlargement.

Diagnosis and differential diagnosis of SI is carried out using instrumental methods.

Acute stroke

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This initial period of development of stroke. It lasts on average twenty-one days, sometimes less. In this period the growth of pathogenic processes in tissues of the brain, especially intensively during the first six hours of the disease.

Distinguish the following stages OI:

• Forming the nucleus of the damaged brain cells 5-8 minutes;
• The increase in the penumbra (region of metabolic changes around the core of infarction of the brain):
• 50% within 1 hour and 30 minutes;
• by 80% within 6 hours.

Six hours is the time of "therapeutic window"when it is possible to conduct therapeutic interventions with maximum effect. From the first minute included a pathogenetic cascade, which at the cellular level begins with the cessation of the blood flow and ends with apoptosis (death) of brain cells. In the absence of treatment, the apoptosis of cells expands exponentially. 3-5 days damaged brain cells undergo necrosis, there comes a partial localization of the process.

Next is the formation and/or development of neurological disorders in the form of cerebral and focal symptoms.

Intensive therapy in the period of"therapeutic window" includes:

1. Improvement in hemodynamics of brain tissue through intravenous injection of physiological solutions;

2. Neuroprotection (protection) of brain cells.

3. The improvement of the rheological (viscosity) and coagulation (clotting) of blood properties;

4. Improvement of blood microcirculation.

5. Prevention of brain edema.

A minor stroke

It is also called a minor stroke (MIS). The name was given due to relatively rapid (2 - 21 days) symptoms of neurological deficit.

Syndrome of neurological deficit accompanied by two or three or more of the following symptoms:

• Unsteady gait;
• Hypertonicity of the muscles;
• Mono - or hemiparesis;
• Paralysis of the eyes or head;
• Aphasia/anosmia;

• Seizures/epilepsy;

• Causeless mirth/rage.

While mini-strokes in the brain are formed and preserved foci of cell necrosis. Symptoms of MI are similar to transient ischemic attacks (TIA).

The fundamental difference between the stroke from transient ischemic attacks is that when TIA:

• There are the symptoms of neurological deficit;
• CT/MTR does not detect the focus of necrosis (ischemia) in the brain.

Development of small stroke, it is noted in the age group from 25 to 45 years. Sexual correlation not established.

Reason MI – a combination of the following factors:

• Hypertension;
• Regular intake of oral contraceptives and other drugs that increase blood viscosity;
• Venous thrombosis;
• Systemic blood diseases;

• Migraine;

• Drugs, alcohol;
• Injuries to the head and neck.

A minor stroke – a risk factor for the development of one of the types of completed stroke. Repetitive MI – the cause of the decline of intelligence and dementia.

Repeated stroke

The main cause of recurrent stroke – transferred cerebrovascular disease (TSVB). Assume that TSVB – this is the stroke and TIA. In the first year in individuals who have had large strokes may develop:

• Repeated strokes;
• Dementia disorders (acquired decline of intelligence in varying degrees);
• Death.

Impact on risk factors is a real chance of prevention of recurrent stroke. Prevention must be consistent and continuous.

The standard algorithm of exposure to risk factors for secondary stroke has a designation – A-b-C therapy (antihypertensive, B - blockers, statins). For the prevention of recurrent strokes are applied:

• Antihypertensive drugs (micardis, aggrenox);
• Blockers of thrombosis.
• Statins to counteract the formation of cholesterol. Drugs from the group of the statins use to block the enzyme (HGM-CoA) involved in cholesterol production. This purpose is prescribed lovastatin, fluvastatin, atorvastatin, rosuvastatin, and others.

Risk factors for stroke

Smoking and alcohol are some of the main risk factors for stroke, especially in older age. Smoking and alcohol together greatly increases the riskof developing cardiovascular disease, in addition, alcohol contributes to weight gain.

The intake of certain medicines without a doctor's prescription leads to the risk of developing heart disease and the blood, which can cause a stroke. The probability of stroke is considerably increased with the use of oral contraceptives containing estrogen. This risk increases with use of oral contraceptives in the female population, have high blood pressure.

It is necessary to monitor the level of cholesterol in the blood, since its increased concentration is one of the risk factors for stroke. To increase the level of cholesterol results in an incorrect (saturated fats) and irregular meals.

Many times increases the risk of stroke, arterial hypertension, especially in combination with all the above factors. You need to be careful to pregnant women suffering from hypertension, and women taking oral contraceptives.

One of the reasons for the development of cardiovascular diseases is physical inactivity (sedentary lifestyle). Need daily to do morning exercises, jog and walk in the fresh air. The implementation of these recommendations has a positive effect on the maintenance of blood sugar levels and helps to reduce blood pressure. Huge risk of stroke in people with more weight, even in the absence of other risk factors. A lot of weight contributes to the development of high blood pressure, diabetes, and creates an increased load on the heart muscle.

The risk of stroke increases in people with diabetes. A huge percentage of patients with diabetes die from the effects of stroke.

A huge role in the occurrence of stroke plays mental condition of the person. Stresses, anxiety, nervous stress increase the risk of developing the disease, especially for people who have previously suffered a stroke.

The effects of stroke

Excluding deaths, the proportion of patients returning to normal or partially limited employment. The slow recovery of body functions and the impossibility for 3-3. 5 months of returning to work, the patient is sent for medical-social examination (MSE). Medical Commission (MC) will decide on the continuation of treatment of sick leave or the need for a definition of III or II groupdisability. When considering the grounds of disability VK takes into account the resistance and duration of the effects of stroke:

• Pyramidal defects (movement disorders - paresis, paralysis);
• Extrapyramidal motor (speech disorder, slow movement of the current side of the body, inability to care for self);
• Extrapyramidal hyperkinesias (reduction of motor functions, inability to maintain a certain posture);
• Ataxic disorders;
• Violations of visual functions in the form of partial or complete loss of vision;
• Cerebral dysfunction in the form of aphasia;
• Epileptic seizures;
• Oppression of mental functions (dementia);

• Complications of the cardiovascular system (peripheral edema, weakness).

Swelling of the legs after stroke

Swelling attributed to long-term effects of a stroke, caused by failure of the cardiovascular system of the body. Swelling characterized by:

• The slow development and conservation within a few hours;
• Localization on the limbs, spreading upwards and symmetry;
• Dense texture, with pressure remains fossa.

Of the available means of prevention of edema of the legs allowed the use of diuretics of plant origin (kanefron, zistan), herbs, or fees, possess a diuretic effect. Gently apply ointments and fluid as rubbing may damage the skin.

Brain edema in stroke

This complication can develop at any stage of the stroke, often within the first hours of the pathogenesis. Cerebral edema is an increase in intracranial pressure due to abnormal swelling of glial brain tissue. Brain edema in stroke – a consequence of the violations of cerebral circulation, caused by a blockage of a major vessel of the brain and its pool and the effusion of the liquid portion of blood outside the vascular bed.

Prevention of cerebral edema – a mandatory part of treatment the initial period of stroke, regardless of the presence of symptoms.

The event is conducted by a specialised team, responsible for carrying out therapy of critical patients.

The team performs the following steps.

• Maintains a stable hemodynamics;
• Selectively controls blood pressure (only withhypertension and/or with simultaneous development of pulmonary edema and some other States) shown – clonidine, captopril, atenolol, labetalol, benzogeksony and other blood pressure reduction is not more than 15% from baseline;
• Prevents swelling of the brain and lungs, shown artificial ventilation and drug therapy;
• Relieves the syndrome of psychomotor agitation and/or convulsions, shows benzodiazepine drugs, non-narcotic dose of ghb;
• Temperature above 37.5°C, it is advisable to reduce shown paracetamol and physical methods;
• Controls the level of glucose in the blood. When hyperglycemia is shown a short-acting insulin. Intravenous glucose is contraindicated. Not recommended: Dibazol, nifedipine, papaverine hydrochloride, Vinpocetine, nicergoline, papaverine, furosemide and mannitol, without monitoring the osmolarity of blood.

Paralysis after a stroke

Violations of motor activity of varying degrees of regression are frequent companions of strokes.

Usually disorders are manifested in the form of a paresis (partial loss of movement) and paralysis (complete loss of motor activity).

In strokes see:

• Monoplegia – paralysis of one limb (arm or leg);
• The hemiplegia – paralysis of the hands and feet of one side of the body;
• The paraplegia is paralysis of the two arms or legs.

For peripheral paralysis characterized by a complete absence of motor activity in the affected area of the body.

For Central paralysis is characterized synkinesia – friendly movement. When synkinesis paralyzed arm or leg does not act independently, but the boost of a healthy arm or leg is paralyzed limb performs a similar movement.

Simultaneously with the paralysis occur speech disorders in aphasia or difficulty with pronunciation of words, and misunderstanding their own speech errors.

Coma after stroke

Coma after a stroke is depression of the Central nervous system as a result of secondary disorders of cerebral circulation, or apoplectically coma. It develops on the background of stroke and increase in body temperature, as a consequence of necrotic processes in the brain and purulent pathologies (of complications such as bedsores and other).

Coma is characterized by stages, starts prekoma – confusion.

Regression of reflexes is manifested in four stages:

• Stun – stage 1;
• Deep sleep (SOPOR) – stage 2;
• Loss of corneal and palpebral reflexes stage 3;

• Loss of deep reflexes, muscle atony stage 4.

How long coma after a stroke?

The duration of coma after a stroke – from several hours to several weeks.

The duration of coma depends on:

• Its depth – in the 1-2 stages possible removal from the coma, 3-4 stage the prognosis is poor;
• The General condition of the patient;
• Completeness of maintenance of the patient's life;
• Care care patients who are unconscious (prevention of bedsores).

Coma of 3 degrees

The third degree is also called atonic coma.

Signs of coma III degree manifest:

1. The lack of:

   • pain response;
   • the corneal reflex (closing the eyes in response to irritation of the cornea);
   • pupil response (lack of response to illumination of the eye).

2. Reduction:

   • gag reflex;
   • tendon reflexes;
   • muscle tone;
   • blood pressure;
   • body temperature;
   • the rhythm of the breath.

3. Involuntary actions:

   • paralytic miosis (permanently dilated pupil);
   • local or generalized seizures;
   • acts of urination and defecation.

Forecast

The prediction of outcome of stroke in a coma stage III (atonic coma) "bad"or"lethal". Base medical decisions – lack of vital signs habitus of the patient.

Lethal prognosis of stroke can also be the case:

• Extensive bleeding in severe Gorodnichenko syndrome (seizures increase muscle tone in the initial stages of coma);
• Rough breathing disorders;
• Hyperthermia above 40-42 degrees;
• Recurrent stroke with severe residual effects (paralysis, dementia disorders);
• Stroke on the background of cancer in incurable (hopeless) stage.

A favorable outcome is possible if:

• Transient ischemic attacks (potential stroke condition);
• Small strokes(mini-strokes);
• Timely treatment of certain types of stroke in the earlier period 3-6 hours after the onset of the first signs of disease.

What to do, how to recover after a stroke?

The recovery period is men and women is roughly the same time. Adaptation depends on the individual characteristics of the organism. The recovery period after stroke is quick, and patients return to a relatively normal existence within two to three months. With extensive stroke rehabilitation long-term or lifelong.

It is desirable the involvement of rehabilitation professionals in the field of neurology, massage, chiropractic, speech therapists, dieticians. The individual stages of rehabilitation possible in the hospital, dispensary and sanatorium.

During the period of rehabilitation patients who had a massive stroke, as shown:

• Electrical stimulation with sine wave currents;
• Magnetic therapy;
• Electrophoresis in oculo-occipital location of the electrodes;
• Ozokeritotherapy.

To normalize motor and sensory functions recommended combination of massage, manual therapy and acupuncture. Recovery of neuropsychological functions is happening in the classroom in an outpatient/home with an individual therapist or in group method, it takes a year or more.

Topic: rehabilitation and recovery after stroke in the home

In the rehabilitation period following medications:

• In ischemic stroke – Actovegin, Berlition, instenon, gliatilin;
• In hemorrhagic stroke – Actovegin and gliatilin;
• For correction of muscle tone – mydocalm and sirdalud;
• As antidepressants, trittico, coaxil, stimuloton.

Products for stroke prevention

The world population as of July 2011 was already more than 7 billion, of which about one billion are at risk for stroke. For every six seconds on the planet from a stroke one person dies.

Hearing these data, we have to ponder whether it is possible to reduce the number of deaths from stroke. Although the number of strokes higher and higher, the researchers indicate that 85% of these cases, it is possible to prevent stroke bymaking changes to your daily lifestyle and diet. Must not abuse alcohol, to include in your daily menu of fresh fruits and vegetables, preferably home that contain various chemical additives, but also should regularly perform physical exercises.

Topic: How to make the menu after a stroke?

Fish – product, the use of which at least once a week, according to research, help to avoid stroke. The fact that stroke most often occurs because of the presence of harmful habits: alcohol, Smoking, constant overeating. And fish contains substances such as omega-3 which reduce the risk of stroke. Polyunsaturated fatty acids, they contribute to the stabilization of blood pressure, and lowers the content of cholesterol in the blood.

Coffee is a drink that contains antioxidants that prevent the accumulation of cholesterol in the body, thereby stopping the formation of blood clots in the human brain. With three or four drunk mugs of coffee a day the risk to move the stroke is reduced by 17 %. However, coffee is useful only in limited quantities. For example, when consuming more than seven cups a day the risk of blood clots reduced by only 7 %. Also keep in mind the time that we are talking only about the benefits of organic coffee!

Pears and apples – the fruits, the pulp of which is white in color due to the substance that assists the body in preventing a stroke. This is proved by the data of one study in which participated 20069 man at the age of 40 years. The study lasted 10 years, during which time scientists have recorded 233 cases of stroke. The result concluded that the risk to suffer a stroke was 52 % lower in people who ate fruits and vegetables with white flesh. However, despite the results of various studies, it should be noted that eating various fruits and vegetables in any case improves the immune system and strengthens natural defenses of the body.

* There are contraindications, before applying you should consult with a specialist

okov, Andrey Vladimirovich, doctor-neurologist