DOCSLIB.ORG

EBRSR: Secondary Prevention of Stroke

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
EBRSR: Secondary Prevention of Stroke EBRSR [Evidence-Based Review of Stroke Rehabilitation] 8 Secondary Prevention of Stroke Katherine Salter PhD (cand.), Robert Teasell MD, Norine Foley MSc, Adam Hopfgartner MSc (cand.), Jennifer Mandzia MD, Shannon Janzen MSc, Danielle Rice BA, Mark Speechley PhD Last Updated: September 2016 Abstract The Heart and Stroke Foundation of Canada has estimated that there are approximately 400,000 individuals living with the effects of stroke (Statistics Canada, 2011). While there is disagreement among studies assessing the relative cost associated with secondary compared to first-ever stroke, recurrent strokes appear to contribute a disproportionate share to the overall national burden of stroke, principally due to costs associated with long-term disability (e.g. nursing home care and re-hospitalization). The secondary prevention of stroke includes strategies used to reduce the risk of stroke recurrence among patients who had previously presented with a stroke or TIA. Management strategies, which should be specific to the underlying etiology, include risk factor modification, the use of antithrombotic or anticoagulant drugs, carotid surgery, endovascular treatments. The present review provides information on risk factor management programs, management of hypertension, diabetes, hyperlipidemia, the role of infection, lifestyle modification (diet, smoking, use of alcohol, physical activity) as well as treatment for atherosclerosis and cardiac abnormalities (e.g. atrial fibrillation) and reperfusion techniques. The review may be downloaded in a single document or in single sections corresponding to the topic areas listed above. 8. Secondary Prevention of Stroke pg. 1 of 344 www.ebrsr.com Table of Contents Abstract .............................................................................................................................................1 Table of Contents ...............................................................................................................................2 Key Points ..........................................................................................................................................6 8.1 The Importance of Preventing Recurrent Strokes ..........................................................................7 8.2 Stroke Risk Factors and Risk Factor Management ..........................................................................8 8.2.1 Stroke and TIA as Risk Factors ................................................................................................9 8.2.1.1 Urgent Assessment and Intervention Post-TIA ....................................................................... 10 8.2.1.2 Prediction of Risk for Recurrent Stroke Following TIA ............................................................ 15 8.2.2 Risk Factor Management ...................................................................................................... 17 8.2.2.1 Programs for Risk Management Following Stroke ................................................................. 19 Summary ......................................................................................................................................... 24 References ....................................................................................................................................... 25 Key Points ........................................................................................................................................ 38 8.3 Hypertension ............................................................................................................................. 39 8.3.1 Significance of Hypertension ................................................................................................ 39 8.3.2 Treatment of Hypertension .................................................................................................. 39 8.3.3 Treatment Recommendations .............................................................................................. 50 Summary ......................................................................................................................................... 52 References ....................................................................................................................................... 54 Key Points ........................................................................................................................................ 63 8.4 Managing Diabetes ..................................................................................................................... 64 8.4.1 Significance of Diabetes ....................................................................................................... 64 8.4.2 Management of Diabetes and Associated Macrovascular Complications ............................... 64 8.4.2.1 Glycemic Control ..................................................................................................................... 64 8.4.2.2 Hypertension Control .............................................................................................................. 69 8.4.2.3 Treatment of Dyslipidemia ..................................................................................................... 71 8.4.2.4 Fibrates and Stroke Prevention in Patients with Diabetes ..................................................... 74 8.4.3 Treatment Recommendations .............................................................................................. 76 Summary ......................................................................................................................................... 78 References ....................................................................................................................................... 80 Key Points ........................................................................................................................................ 89 8.5 Hyperlipidemia ........................................................................................................................... 90 8.5.1 The Significance of Elevated Cholesterol Levels ..................................................................... 90 8.5.2 Treatment of Hyperlipidemia and the Risk of Stroke ............................................................. 91 8.5.2.1 Statins and Functional Outcome ............................................................................................. 96 8.5.3 Treatment Recommendations .............................................................................................. 98 Summary ....................................................................................................................................... 100 References ..................................................................................................................................... 101 Key Points ...................................................................................................................................... 108 8.6 Infection .................................................................................................................................. 109 8.6.1 Pneumonia ........................................................................................................................ 109 8.6.2 Other Conditions ............................................................................................................... 111 Summary ....................................................................................................................................... 113 8. Secondary Prevention of Stroke pg. 2 of 344 www.ebrsr.com References ..................................................................................................................................... 114 Key Points ...................................................................................................................................... 118 8.7 Lifestyle Modification ............................................................................................................... 120 8.7.1 Physical Activity ................................................................................................................. 120 8.7.1.1 Stroke Risk ............................................................................................................................. 120 8.7.1.2 Functional Outcomes ............................................................................................................ 124 8.7.1.3 Mortality ............................................................................................................................... 125 8.7.1.4 Interventions to Promote Physical Activity Following Stroke ............................................... 125 8.7.1.5 Physical Activity Recommendations ..................................................................................... 126 8.7.2 Diet ................................................................................................................................... 127 8.7.2.1 Vitamins/Antioxidants .......................................................................................................... 133 8.7.2.2 Homocysteine ....................................................................................................................... 136 8.7.2.3 Treatment Recommendations .............................................................................................
Load more

Recommended publications
  • Installing Chevy & GM Engines in TJ / LJ W Rangler
    Introduction Individuals have been successfully installing popular Chev- rolet and GM engines to Jeep vehicles since the 1960’s. The Jeep TJ is certainly more sophisticated than their early CJ predecessors, but the swaps can actually be even more successful. Below is a summary of the information we’ve gathered since our first TJ conversion in 2000, and in- cludes the valuable insight of our many customers gained during their installs. The Novak Guide to Despite whatever your experience with this type of work may be, we strongly advise you to read these instructions well. Contained in these instructions are the requirements, tips, hints and tricks of years of performing these conversions, both in our own facility and information we’ve gained from discussing these swaps with our customers. Put this information to good use. Failure to implement the practices and information in these pages may jeopardize the quality of your work, as well as the product warranty. About Your Engine Mounts Novak’s bolt-in / weld-in engine mounts for the Jeep TJ & LJ Wranglers provide immense strength and a rapid and pre- cise GM V6 & V8 engine installation. Ease of Installation Of the four styles of engine mounts discussed in this instruction guide, we have sought the greatest ease of installation achievable with each of them without compromising engineering. Strength The Novak mounts feature a thick 3/16 steel construc- tion and a welded box design for the maximum strength available. They employ the best engineering and geometry to assure that they’ll survive even the wildest of engines.
    [Show full text]
  • On Kernels, Β-Graphs, and Β-Graph Sequences of Digraphs Kevin D
    On Kernels, b-graphs, and b-graph Sequences of Digraphs By Kevin D. Adams Submitted to the Department of Mathematics and the Graduate Faculty of the University of Kansas in partial fulfillment of the requirements for the degree of Master of Arts Margaret Bayer, Chairperson Committee members Jeremy Martin Yunfeng Jiang Date defended: 5-1-2015 The Master’s Thesis Committee for Kevin D. Adams certifies that this is the approved version of the following master’s thesis : On Kernels, b-graphs, and b-graph Sequences of Digraphs Margaret Bayer, Chairperson Date approved: 5-1-2015 ii Abstract We begin by investigating some conditions determining the existence of kernels in various classes of directed graphs, most notably in oriented trees, grid graphs, and oriented cycles. The question of uniqueness of these kernels is also handled. Attention is then shifted to g-graphs, structures associated to the minimum dominating sets of undirected graphs. I define the b-graph of a given digraph analogously, involving the minimum absorbant sets. Finally, attention is given to iterative construction of b- graphs, with an attempt to characterize for what classes of digraphs these b-sequences terminate. iii Acknowledgements I would like to thank my advisor Professor Marge Bayer for her patience and guid- ance, as well as my committee members Professors Jeremy Martin and Yunfeng Jiang for teaching me some very interesting algebra and combinatorics. Thanks to all of the professors from whom I’ve learned so very much during my time at KU. Thank you to my lovely fiancée Elise for her constant support and encouragement, even across long distances.
    [Show full text]
  • The Epidemiology of Silent Brain Infarction: a Systematic Review of Population-Based Cohorts Jonathon P Fanning1,2*, Andrew a Wong1,3 and John F Fraser1,2
    Fanning et al. BMC Medicine 2014, 12:119 http://www.biomedcentral.com/1741-7015/12/119 RESEARCH ARTICLE Open Access The epidemiology of silent brain infarction: a systematic review of population-based cohorts Jonathon P Fanning1,2*, Andrew A Wong1,3 and John F Fraser1,2 Abstract Background: Cerebral infarction is a commonly observed radiological finding in the absence of corresponding, clinical symptomatology, the so-called silent brain infarction (SBI). SBIs are a relatively new consideration as improved imaging has facilitated recognition of their occurrence. However, the true incidence, prevalence and risk factors associated with SBI remain controversial. Methods: Systematic searches of the Medline and EMBASE databases from 1946 to December 2013 were performed to identify original studies of population-based adult cohorts derived from community surveys and routine health screening that reported the incidence and prevalence of magnetic resonance imaging (MRI)-determined SBI. Results: The prevalence of SBI ranges from 5% to 62% with most studies reported in the 10% to 20% range. Longitudinal studies suggest an annual incidence of between 2% and 4%. A strong association was seen to exist between epidemiological estimates of SBI and age of the population assessed. Hypertension, carotid stenosis, chronic kidney disease and metabolic syndrome all showed a strong association with SBI. Heart failure, coronary artery disease, hyperhomocysteinemia and obstructive sleep apnea are also likely of significance. However, any association between SBI and gender, ethnicity, tobacco or alcohol consumption, obesity, dyslipidemia, atrial fibrillation and diabetes mellitus remains unclear. Conclusions: SBI is a remarkably common phenomenon and endemic among older people. This systematic review supports the association of a number of traditional vascular risk factors, but also highlights disparities between clinically apparent and silent strokes, potentially suggesting important differences in pathophysiology and warranting further investigation.
    [Show full text]
  • +1. Introduction 2. Cyrillic Letter Rumanian Yn
    MAIN.HTM 10/13/2006 06:42 PM +1. INTRODUCTION These are comments to "Additional Cyrillic Characters In Unicode: A Preliminary Proposal". I'm examining each section of that document, as well as adding some extra notes (marked "+" in titles). Below I use standard Russian Cyrillic characters; please be sure that you have appropriate fonts installed. If everything is OK, the following two lines must look similarly (encoding CP-1251): (sample Cyrillic letters) АабВЕеЗКкМНОопРрСсТуХхЧЬ (Latin letters and digits) Aa6BEe3KkMHOonPpCcTyXx4b 2. CYRILLIC LETTER RUMANIAN YN In the late Cyrillic semi-uncial Rumanian/Moldavian editions, the shape of YN was very similar to inverted PSI, see the following sample from the Ноул Тестамент (New Testament) of 1818, Neamt/Нямец, folio 542 v.: file:///Users/everson/Documents/Eudora%20Folder/Attachments%20Folder/Addons/MAIN.HTM Page 1 of 28 MAIN.HTM 10/13/2006 06:42 PM Here you can see YN and PSI in both upper- and lowercase forms. Note that the upper part of YN is not a sharp arrowhead, but something horizontally cut even with kind of serif (in the uppercase form). Thus, the shape of the letter in modern-style fonts (like Times or Arial) may look somewhat similar to Cyrillic "Л"/"л" with the central vertical stem looking like in lowercase "ф" drawn from the middle of upper horizontal line downwards, with regular serif at the bottom (horizontal, not slanted): Compare also with the proposed shape of PSI (Section 36). 3. CYRILLIC LETTER IOTIFIED A file:///Users/everson/Documents/Eudora%20Folder/Attachments%20Folder/Addons/MAIN.HTM Page 2 of 28 MAIN.HTM 10/13/2006 06:42 PM I support the idea that "IA" must be separated from "Я".
    [Show full text]
  • Health History Form ALLERGIES Are You Latex-Sensitive? Y N List Any Medication(S) You Are
    Health History Form Hello and thank you for choosing Fusion Physical Therapy as the provider for your current healthcare need(s)! We look forward to working with you to help make your day a little easier! To ensure you receive a complete and thorough evaluation, please provide us with your important background information on the following form. If you do not understand a question, leave it blank and your therapist will assist you. Name:_______________________________________ Age: ______ Gender: _______ Occupation:Patient ___________________________________________________________ Characteristics Leisure Activities: ______________________________________________________ ALLERGIES Are you latex-sensitive? Y N List any medication(s) you are allergic to: ___________________________________ _____________________________________________________________________ List any other allergies we should know about:_______________________________ Please check (√) any of the following providers whose care you are under: ___Current medical Physicians doctor & ___ osteopath ___ dentist ___ psychiatrist ___ psychologist Non-physician providers ___ physical therapist ___ chiropractor ___ other: __________________________ Date of your last physical examination: ______________________ Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following? Y NRelevant Alcoholism Family History (chemical dependence) Y N High blood pressure Y N Cancer Y N Inflammatory arthritis Y N Depression Y N Kidney disease Y N Diabetes Y N Stroke Y N Heart Disease 1 | P a g e Health History Form Have you EVER been diagnosed as having any of the following conditions? Y N Arthritic conditions. If Y, what kind: _______________________________ Y N Asthma Y N Blood Clots Y N Cancer. If Y, what kind: _________________________________________ Y N Chemical dependence (e.g. alcoholism) Y N Circulation problems Y N Depression Y N Diabetes Y N Heart problems.
    [Show full text]
  • Risk Factors for Recurrent Arterial Ischemic Stroke in Children and Young Adults
    brain sciences Review Risk Factors for Recurrent Arterial Ischemic Stroke in Children and Young Adults Beata Sarecka-Hujar 1,* and Ilona Kopyta 2 1 Department of Pharmaceutical Technology, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, 41-200 Sosnowiec, Poland 2 Department of Paediatric Neurology, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland; [email protected] * Correspondence: [email protected] or [email protected]; Tel.: +48-32-269-9820 Received: 14 November 2019; Accepted: 30 December 2019; Published: 2 January 2020 Abstract: Arterial ischemic stroke (AIS) experienced at a young age is undoubtedly a serious medical problem. AIS very rarely occurs at a developmental age, whereas in young adults, it occurs with a higher frequency. The etiologic mechanisms of AIS occurring in childhood and adulthood differ. However, for both age populations, neurological consequences of AIS, including post-stroke seizures, motor disability, and recurrence of the disease, are connected to many years of care, rehabilitation, and treatment. Recurrent stroke was observed to increase the risk of patients’ mortality. One of the confirmed risk factors for recurrent stroke in children is the presence of vasculopathies, especially Moyamoya disease and syndrome, and focal cerebral arteriopathy of childhood (FCA). FCA causes a 5-fold increase in the risk of recurrent stroke in comparison with idiopathic AIS. In turn, young adults with recurrent stroke were found to more often suffer from hypertension, diabetes mellitus, or peripheral artery disease than young patients with first-ever stroke. Some reports also indicate relationships between specific genetic polymorphisms and AIS recurrence in both age groups.
    [Show full text]
  • Inadequate Knowledge About Sickle Cell Disease Among African
    Michael R. DeBaun MD, MPH Director of Vanderbilt, Meharry Center of Excellence for Sickle Disease Professor of Pediatrics and Medicine Vanderbilt University School of Medicine Questions • What is the impact of primary stroke prevention in children with SCD? • What is the impact of blood transfusion therapy on secondary stroke prevention? – Should we increase the threshold from 30% to 50% • Should we perform exchange transfusion therapy at initial presentation for focal neurological examination? • How common is silent stroke and how should we transfuse for silent strokes? Changing Epidemiology of Overt Strokes prior to 1998 Changing Epidemiology of Overt Strokes After 1998 Estimated Hazard Function based on recent literature and after routine use of TCD ; J Pediatr. 2010 Apr 29. 18 year old with hemoglobin SS is seen in the ED for an acute neurological deficit. What should be the initial management? A. Simple transfusion only B. Exchange transfusion only with the goal to decrease hemoglobin S level less than 30% C. Simple transfusion and exchange transfusion with a goal to decrease hemoglobin S levels to less than 30% Treatment of Acute Stroke • Goals of treatment of acute stroke – Restore cerebral blood flow – Maximize tissue oxygen delivery – Reverse neurological injury – Prevent further neurological injury • Methods of treatment – Simple blood transfusion – Exchange blood transfusion (manual exchange vs. erythrocytapheresis) Consequence of Stroke in SCD • High Recurrence Rate (Progressive) • Motor, Speech, Sensory Impairment • Cognitive
    [Show full text]
  • Old Cyrillic in Unicode*
    Old Cyrillic in Unicode* Ivan A Derzhanski Institute for Mathematics and Computer Science, Bulgarian Academy of Sciences [email protected] The current version of the Unicode Standard acknowledges the existence of a pre- modern version of the Cyrillic script, but its support thereof is limited to assigning code points to several obsolete letters. Meanwhile mediæval Cyrillic manuscripts and some early printed books feature a plethora of letter shapes, ligatures, diacritic and punctuation marks that want proper representation. (In addition, contemporary editions of mediæval texts employ a variety of annotation signs.) As generally with scripts that predate printing, an obvious problem is the abundance of functional, chronological, regional and decorative variant shapes, the precise details of whose distribution are often unknown. The present contents of the block will need to be interpreted with Old Cyrillic in mind, and decisions to be made as to which remaining characters should be implemented via Unicode’s mechanism of variation selection, as ligatures in the typeface, or as code points in the Private space or the standard Cyrillic block. I discuss the initial stage of this work. The Unicode Standard (Unicode 4.0.1) makes a controversial statement: The historical form of the Cyrillic alphabet is treated as a font style variation of modern Cyrillic because the historical forms are relatively close to the modern appearance, and because some of them are still in modern use in languages other than Russian (for example, U+0406 “I” CYRILLIC CAPITAL LETTER I is used in modern Ukrainian and Byelorussian). Some of the letters in this range were used in modern typefaces in Russian and Bulgarian.
    [Show full text]
  • C BINGO HOUSE HALE M6ASSAD0R Itanrlfffittr Leuttititg Mrraui
    1; WEDNESDAY, NOVEMBER 27, 1968 . PAGE K)URTEEN • w . iianrh^Bti^r lEtipttttts Iffralb Manchester Stores Open Tonight for Christmas Shopping Memb«m o t John Mather a member of Me financing com­ Chapter, Orter o f DeMolay, will mittee and olMinman o f the In- About Town have a coffee and doc^hnut Knight Head J u st ssy: utand tomonrowr at Keith's vestment oammiAtM. He ia ohe A memorial Mara lor the late of the original membeta of the Avwrngt Dafly Net PrsM R rii The Weather ParWng area from 9 am . imtil JProaMant, John f . KennedjH .CktiBens Advisory Oouncfl of "Charts It, PUass* For the Week B aM Fcreceet of U. 8. Weather B m e u after the road race. AS pro­ Of Kiwani& win be celebrated at noon Fri­ the Manoheeter Coeniminlty Neveraber 16, IMS day at the Cathedral of St. ceeds will be donated to the at Wlfidy tonight. Rein teperlng muscular dyatrophy reaearch N. WiUlem Knight o f 66 OoUege. He le currently eendng Joeeph, Hartford, at the requeet as ita oorreepoodlng secretary, off to .bower*. Low In SO* by haid. White St. was eleoM preailent of Mm Connecticut Federation of treaeurer and chairman of the 13,891 morning. 8etarday rionSy, windy Democratic Women’* Olube. of the KtwanU Club of Man­ itanrlfffitTr lEuTtititg MrraUi flnanoe committee. end eolder with eeettered enow Mynttc Review, Women’s chester yesterday. He le a vice ^ Mepiber ef the AnSIt Knight ie ateo a treasurer of B un ea eC OtrealettMi Annie*. Opm houM, In honor of the BaneAt Aenodaition, will have president of the Connecticut MdneheUer" A City of Village Charm Wth wedding annlverrary of Mr.
    [Show full text]
  • Atrial Fibrillation and Silent Stroke: Links, Risks, and Challenges
    Vascular Health and Risk Management Dovepress open access to scientific and medical research Open Access Full Text Article REVIEW Atrial fibrillation and silent stroke: links, risks, and challenges Kathrin Hahne¹ Abstract: Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a projected Gerold Mönnig2 number of 1 million affected subjects in Germany. Changes in age structure of the Western Alexander Samol¹ population allow for the assumption that the number of concerned people is going to be doubled, maybe tripled, by the year 2050. Large epidemiological investigations showed that AF leads to a ¹Division of Cardiology, 2Division of Electrophysiology, Department of significant increase in mortality and morbidity. Approximately one-third of all strokes are caused Cardiovascular Medicine, University by AF and, due to thromboembolic cause, these strokes are often more severe than those caused Hospital Münster, Münster, Germany by other etiologies. Silent brain infarction is defined as the presence of cerebral infarction in the absence of corresponding clinical symptomatology. Progress in imaging technology simplifies diagnostic procedures of these lesions and leads to a large amount of diagnosed lesions, but For personal use only. there is still no final conclusion about frequency, risk factors, and clinical relevance of these infarctions. The prevalence of silent strokes in patients with AF is higher compared to patients without AF, and several studies reported high incidence rates of silent strokes after AF ablation procedures. While treatment strategies to prevent clinically apparent strokes in patients with AF are well investigated, the role of anticoagulatory treatment for prevention of silent infarctions is unclear. This paper summarizes developments in diagnosis of silent brain infarction and its context to AF.
    [Show full text]
  • 5892 Cisco Category: Standards Track August 2010 ISSN: 2070-1721
    Internet Engineering Task Force (IETF) P. Faltstrom, Ed. Request for Comments: 5892 Cisco Category: Standards Track August 2010 ISSN: 2070-1721 The Unicode Code Points and Internationalized Domain Names for Applications (IDNA) Abstract This document specifies rules for deciding whether a code point, considered in isolation or in context, is a candidate for inclusion in an Internationalized Domain Name (IDN). It is part of the specification of Internationalizing Domain Names in Applications 2008 (IDNA2008). Status of This Memo This is an Internet Standards Track document. This document is a product of the Internet Engineering Task Force (IETF). It represents the consensus of the IETF community. It has received public review and has been approved for publication by the Internet Engineering Steering Group (IESG). Further information on Internet Standards is available in Section 2 of RFC 5741. Information about the current status of this document, any errata, and how to provide feedback on it may be obtained at http://www.rfc-editor.org/info/rfc5892. Copyright Notice Copyright (c) 2010 IETF Trust and the persons identified as the document authors. All rights reserved. This document is subject to BCP 78 and the IETF Trust's Legal Provisions Relating to IETF Documents (http://trustee.ietf.org/license-info) in effect on the date of publication of this document. Please review these documents carefully, as they describe your rights and restrictions with respect to this document. Code Components extracted from this document must include Simplified BSD License text as described in Section 4.e of the Trust Legal Provisions and are provided without warranty as described in the Simplified BSD License.
    [Show full text]
  • Acquisition of L2 Phonology – Spanish Meets Croatian
    ACQUISITION OF L2 PHONOLOGY – SPANISH MEETS CROATIAN Maša Musulin University of Zagreb Article History: Submitted: 10.06.2015 Accepted: 08.08.2015 Abstract: The phoneme is conceived as a mental image that is stored in our mind and then represented by sounds in speech and graphemes in writing for phonologically based alphabets. The acquisition of L2 phonology includes two very important skills – reading and writing. The information stored in the mind of a speaker interferes with new information produced by the L2 (Robinson, Ellis 2008; Nathan, 2008). What is similar or equal in the target language to one's native language is, while unknown, incorporated one way or another into an existing model, based on prototypicality (Pompeian, 2004, Moreno Fernández, 2010). The process of teaching the sounds, letters and alphabet to foreign students is much shorter than for native speakers because to a foreign student must be given a tool for writing as soon as possible as they have to write what they are learning and memorize new language units (Celce-Murcia, Brinton, Goodwin, 1996). This paper discusses one type of difficulties Spanish learners of Croatian as L2 face when they are introduced to phonology through letters which represent Croatian sounds in order to display the influence of their preexisting phonological concepts. The subjects are ten students from Spain and Latin America. Their task was to read a group of words containing sounds that were predictably hard for them, minimal pairs and a short text. Keywords: phoneme, grapheme, letter, phonological awareness, foreign language 1. INTRODUCTION As literacy has a big impact on phonological awareness in languages with phonological writing, the graphemes that represent the phonemes, including letters, make an integral part of their mental image.
    [Show full text]