51
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Abstract
The existence of a system in the human body capable of inducing the dissolution of endogenous pathologically formed thrombi was appreciated in ancient times. Considered in detail in this article are the data that have elucidated the physiologic regulation of which plasmin formation is dependent on, the plasma concentration of plasminogen, availability of activators of plasminogen in the plasma and surrounding tissue environment, the concentration of naturally present inhibitors, and the existence of fibrin in the circulation. Important in this rapidly progressive scientific discipline is consideration of the factors which control the synthesis of the components of this proteolytic enzyme system. Recently abundant information has indicated that this plasminogen-plasmin proteolytic enzyme system can be utilized therapeutically. Knowledge of the mechanisms of this system has permitted identification of agents that can be exogenously administered to releave thrombotic obstruction to blood flow in the venous (pulmonary emboli, deep vein thrombosis) and arterial (peripheral and central vessels) circulatory systems. Particularly important is the demonstration that thrombolytic agents can directly attack and alleviate the immediate cause of acute myocardial infarction. As a result of the innovations in the present decade, it is evident that the plasminogen system can be advantageously employed to reverse the pathologic effects of all thrombotic diseases.
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52
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Abstract
The authors present a case of proximal myopathy secondary to epsilon-aminocaproic acid (EACA) administration. This well recognized entity does not occur immediately after institution of therapy, but follows a delay of several days and a cumulative dose. Its consequences include a spectrum of symptoms from myalgias to severe myopathy with rhabdomyolysis, myoglobinuria, and acute tubular necrosis. A presenting symptom of calf pain in a patient receiving EACA should not automatically imply deep vein thrombosis. Serial creatine phosphokinase measurements are essential in monitoring a patient undergoing EACA therapy, especially after 2 weeks of treatment and a total dose of greater than 500 gm.
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53
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Burchiel KJ, Schmer G. A method for monitoring antifibrinolytic therapy in patients with ruptured intracranial aneurysms. J Neurosurg 1981; 54:12-5. [PMID: 7463112 DOI: 10.3171/jns.1981.54.1.0012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A rapid fluorometric assay technique has been utilized to assess the degree of fibrinolytic inhibition in 20 patients with ruptured intracranial aneurysms treated with epsilon-aminocaproic acid (EACA). This method quantitates the available plasminogen activity (APA) of plasma, and has proven to be a reliable means of monitoring antifibrinolytic therapy. Determination of the plasma APA also permits correlation of the level of fibrinolytic activity with putative complications of EACA therapy. Normal control plasma APA was 3.1 +/- 0.7 CTA units/ml, but in patients with subarachnoid hemorrhage (SAH), pretreatment fibrinolytic activity was supranormal at 3.78 +/- 0.88 CTA units/ml. During continuous intravenous administration of EACA (1.5 gm/hr) in patients with SAH, the plasma fibrinolytic activity was decreased to 0.9 +/- 0.31 CTA units/ml. A case described which examplifies the use of this assay. In addition, an approach to monitoring antifibrinolytic therapy using the plasma APA is proposed.
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54
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Abstract
Drugs commonly used for diagnostic and therapeutic purposes may cause toxic nephropathy. There are several factors that account for renal susceptibility. Precise mechanisms of toxicity are generally not known, and therapy depends upon recognizing and removing the offending agent. Drugs that affect identifiable segments of the nephron or that produce similar syndromes are grouped together. Measures that might prevent toxicity are presented.
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55
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56
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Biswas CK, Milligan DA, Agte SD, Kenward DH, Tilley PJ. Acute renal failure and myopathy after treatment with aminocaproic acid. BRITISH MEDICAL JOURNAL 1980; 281:115-6. [PMID: 7427206 PMCID: PMC1713609 DOI: 10.1136/bmj.281.6233.115-a] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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57
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Ishii M, Suzuki S, Iwabuchi T, Julow J. Effect of antifibrinolytic therapy on subarachnoid fibrosis in dogs after experimental subarachnoid haemorrhage. Acta Neurochir (Wien) 1980; 54:17-24. [PMID: 7435291 DOI: 10.1007/bf01401939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The effect of antifibrinolytic therapy on posthaemorrhagic subarachnoid fibrosis was observed experimentally in dogs with the scanning electron microscope (SEM). The subchronic subjects, given intravenous injections of tranexamic acid (1 mg/day) for 12 days and sacrificed 3 weeks after cisternal blood injection, showed residual clot with thick fibrosis, especially around the haemorrhage. The chronic subjects, to which the same procedure was applied and which were sacrificed three months after cisternal blood injection, showed significant increases in the subarachnoid fibrosis, most remarkably in the parasagittal region. Tranexamic acid is widely used for preventing the recurrence of subarachnoid haemorrhage. However, it was revealed in this study that antifibrinolytic therapy might increase chronic posthaemorrhagic subarachnoid fibrosis, which is considered to be responsible for communicating hydrocephalus by disturbing epicortical CSF flow.
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58
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Gelmers HJ. Prevention of recurrence of spontaneous subarachnoid haemorrhage by tranexamic acid. Acta Neurochir (Wien) 1980; 52:45-50. [PMID: 7376944 DOI: 10.1007/bf01400945] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Tranexamic acid as an antifibrinolytic agent has been investigated in a controlled study in patients with recent subarachnoid haemorrhage. It is concluded that tranexamic acid improves neither rebleeding rates, nor mortality. Predominantly thrombotic complications have been noted as a more serious side effect of tranexamic acid.
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59
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Fodstad H, Liliequist B. Spontaneous thrombosis of ruptured intracranial aneurysms during treatment with tranexamic acid (AMCA). Report of three cases. Acta Neurochir (Wien) 1979; 49:129-44. [PMID: 517175 DOI: 10.1007/bf01808955] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Radiographically verified spontaneous disappearance of medium-sized arterial cerebral aneurysms is seldom reported, and only three times in connection with antifibrinolytic therapy (EACA). In our clinic repeat angiograms have shown non-filling of the aneurysms in three patients during treatment with tranexamic acid (AMCA) two, three, and four weeks respectively after primary bleeds. Initially, all three patients had severe radiological vasospasm associated with neurological deterioration. Follow-up angiograms have demonstrated partial reappearance of the aneurysm after one month in one patient and complete disappearance of the aneurysms in the other two patients after 9 and 22 months respectively. In two cases occlusion of cerebral arteries occurred. With regard to the higher risk of severe vasospasm and occlusion of cerebral arteries in our opinion it should not be a therapeutic goal to try to achieve a thrombosis of a ruptured aneurysm with antifibrinolytic drugs. The reason for spontaneous aneurysm thrombosis during treatment with AMCA may be a local inhibition of plasminogen activators in and around the aneurysm wall. It may also be related to the sympathomimetic property of the drug, with vasospasm and a subsequent flow-reduction inside the aneurysm or a possible interaction with other drugs and substances.
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60
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Tubbs RR, Benjamin SP, Dohn DE. Recurrent subarachnoid hemorrhage associated with aminocaproic acid therapy and acute renal artery thrombosis. Case report. J Neurosurg 1979; 51:94-7. [PMID: 448423 DOI: 10.3171/jns.1979.51.1.0094] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Epsilon aminocaproic acid (EACA) has been used to prevent rebleeding in patients with subarachnoid hemorrhage (SAH). Although this agent does decrease the frequency of rebleeding, several reports have described thrombotic complications of EACA therapy. These complications have included clinical deterioration and intracranial vascular thrombosis in patients with SAH, arteriolar and capillary fibrin thrombi in patients with fibrinolytic syndromes treated with EACA, or other thromboembolic phenomena. Since intravascular fibrin thrombi are often observed in patients with fibrinolytic disorders, EACA should not be implicated in the pathogenesis of fibrin thrombi in patients with disseminated intravascular coagulation or other "consumption coagulopathies." This report describes subtotal infarction of the kidney due to thrombosis of a normal renal artery. This occlusion occurred after EACA therapy in a patient with SAH and histopathological documentation of recurrent SAH. The corresponding clinical event was characterized by marked hypertension and abrupt neurological deterioration.
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61
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Chandra B. Treatment of subarachnoid hemorrhage from ruptured intracranial aneurysm with tranexamic acid: a double-blind clinical trial. Ann Neurol 1978; 3:502-4. [PMID: 354483 DOI: 10.1002/ana.410030607] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A double-blind clinical trial of tranexamic acid was carried out on 39 patients with fresh subarachnoid hemorrhage from a ruptured aneurysm. Twenty patients received tranexamic acid, 6 gm daily for 14 to 21 days, while 19 patients received conventional therapy of bedrest and dexamethasone when cerebral edema developed, plus isotonic saline. Rebleeding and mortality were reduced by one-fourth and one-fifth, respectively (p less than 0.001). No side-effects were observed. Tranexamic acid is valuable in the treatment of subarachnoid hemorrhage caused by ruptured intracranial aneurysms.
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62
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Abstract
Fifty-seven cases admitted to the Karolinska Hospital 1973-1976 with the diagnosis transient cerebral ischemia were reviewed. Seventeen cases were excluded as not fulfilling the strict TIA definition. An analysis of the records and the supplementary questionnaire of the remaining cases showed considerable sex differences in the stroke-prone profile. In the male group arteriosclerosis in the extracranial cerebral arteries was demonstrated in 90% of these examined by angiography. In the female group factors recognized as interfering with the coagulation system were obvious in more than 70% and two women had fibromuscular dysplasia. These differences may have therapeutic and prognostic implications. In the total material only 35% had hypertension. Diabetes was not present in any of the patients. Of the men 46.6% had abnormal blood lipids against 15.4% of the women. Seventy-five percent of the patients with verified arteriosclerosis were regular smokers. At a mean follow-up time of 18.7 months only one patient, in the untreated group, developed completed stroke.
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63
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64
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Abstract
Coagulopathy, or non-mechanical hemorrhage, complicated the operative course of 17 of 33 (51.5%) patients suffering severe liver trauma. The highest incidence of non-mechanical hemorrhage (66.7%) occurred in patients undergoing anatomic lobectomy. Serial hemostatic parameters were assessed and thrombocytopenia was the most striking abnormality in patients with non-mechanical hemorrhage. The degree of thrombocytopenia was directly correlated with the number of blood transfusions administered. The mean operative blood transfusion requirement was significantly greater in patients with non-mechanical hemorrhage, 25.1 +/- 2.87 (S.E.M.) units, than in those without, 12.2 +/- 1.83 units (p < 0.001). The bulk of this transfusion was given before the onset of clinically overt coagulopathy. Massive transfusion of stored blood was felt to be the most important factor in causing non-mechanical hemorrhage. Convincing evidence for disseminated intravascular coagulation was lacking, and abnormal fibrinolysis was infrequent and mild when observed. Although uneventful in most, in six patients non-mechanical hemorrhage resulted in excessive blood transfusion, unnecessary operation or death. Infusions of platelet concentrate, fresh frozen plasma, and fresh blood were used to successfully treat most cases of non-mechanical hemorrhage. In all cases, these components were not started until non-mechanical hemorrhage was clinically apparent. The value of prophylactic use of blood components is stressed. Because of troublesome side effects associated with the use of prothrombin complex concentrates, these agents are contraindicated in patients with severe liver injury. After receiving concentrates, one patient developed severe hypotension leading to ventricular fibrillation, two developed transient thrombocytopenia and two others demonstrated multiple pulmonary microthrombi at autopsy, a finding not observed in autopsied patients not receiving the concentrates.
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65
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Savdie E, Mahony JF, Storey BG. Control of bleeding after renal biopsy with epsilon-amino-caproic acid. BRITISH JOURNAL OF UROLOGY 1978; 50:8-11. [PMID: 630206 DOI: 10.1111/j.1464-410x.1978.tb02756.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
EACA proved useful in controlling severe bleeding after renal biopsy. In 6 patients who required transfusion for prolonged or severe bleeding, haemorrhage ceased and no further transfusions were necessary after EACA therapy. No serious side-effects were encountered.
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66
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Edgerton MT, Hiebert JM. Vascular and lymphatic tumors in infancy, childhood and adulthood: challenge of diagnosis and treatment. Curr Probl Cancer 1978; 2:1-44. [PMID: 373997 DOI: 10.1016/s0147-0272(78)80001-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The essential features of the major benign and malignant vascular tumors affecting infants, children and adults have been presented. Major emphasis has been placed upon the classification and treatment of hemangiomas, although malignant vascular tumors are discussed, and extensive and selected references are cited. The classification system of hemangiomas presented in this monograph is based upon the clinical prognosis of the angioma. The principles of treatment for hemangiomas based upon our clinical classification are discussed and may be summarized as follows: 1. The diagnostic features and prognosis vary with the variety of the angioma. 2. Spontaneous regression occurs only with juvenile hemangiomas, and the major involution occurs before age 5. 3. Patients with rapidly growing capillary cavernous hemangiomas should be treated with steroids. 4. Treatment modalities that increase scarring of the surface epithelium are contraindicated. 5. Intradermal and cirsoid angiomas do not spontaneously regress. 6. Congenital A-V fistulas require aggressive surgery. 7. The ultimate deformity resulting from angiomas may be greatly reduced by plastic surgical techniques. 8. Radiation therapy is never indicated for the treatment of hemangiomas. 9. The psychologic impact of the congenital deformity on patients is generally more detrimental than comparable postsurgical or traumatic deformities.
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67
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Abstract
Therapy for intravascular coagulation is directed primarily against the underlying disorder. If the latter is not readily correctable or if the patient is bleeding actively, anticoagulation with intermittent administration of heparin by the intravenous route is indicated. If thrombocytopenia is present, heparinization must be accompanied by platelet transfusion. The efficacy of therapy is judged by the cessation of bleeding or thrombosis, improvement of organic dysfunction, and correction of the levels of the coagulation factors, particularly factor V and fibrinogen.
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68
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van Rossum J, Wintzen AR, Endtz LJ, Schoen JHR, de Jonge H. Effect of tranexamic acid on rebleeding after subarachnoid hemorrhage: A double-blind controlled clinical trial. Ann Neurol 1977. [DOI: 10.1002/ana.410020311] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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69
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MacGregor D, Saunders EF, Barkin M, Balfe JW. Successful epsilon-aminocaproic acid therapy in a patient with unexplained hematuria. Clin Pediatr (Phila) 1977; 16:167-8. [PMID: 832441 DOI: 10.1177/000992287701600208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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70
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Abstract
A modern outline of the physiology of coagulation, a simple approach to the use of laboratory investigation for patients with possible clotting disorders in unexplained hematuria and several illustrative cases are presented. The diagnosis and management of localized fibrinolysis in the genitourinary tract and intravascular coagulation as possible causes of post-prostatectomy hemorrhage are discussed. A minimum of a platelet count, fibrinogen assay and, if possible, measurement of fibrinogen-related antigens should be obtained before administration of epsilon aminocaproic acid.
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71
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Sengupta RP, So SC, Villarejo-Ortega FJ. Use of epsilon aminocaproic acid (EACA) in the preoperative management of ruptured intracranial aneurysms. J Neurosurg 1976; 44:479-84. [PMID: 1255236 DOI: 10.3171/jns.1976.44.4.0479] [Citation(s) in RCA: 64] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The authors report their experience with the use of epsilon aminocaproic acid (EACA) in the preoperative management of a series of patients with ruptured intracranial aneurysms. A similar series of patients was taken as control. They found that EACA is of definite value in preventing recurrent hemorrhage in the preoperative period. The significance of antifibrinolytic therapy in ruptured intracranial aneurysms is discussed.
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72
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Kanfer A, Vandewalle A, Beaufils M, Delarue F, Sraer JD. Enhanced antiplasmin activity in acute renal failure. BRITISH MEDICAL JOURNAL 1975; 4:195-7. [PMID: 1191995 PMCID: PMC1674993 DOI: 10.1136/bmj.4.5990.195] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Plasmatic slow plasmin-inhibitor activity was assessed in 20 patients with acute renal failure and 12 controls with the fibrin plate method. The area of fibrinolysis was 250-5 +/- 5 mm2 in the patients and 289 +/- 6mm2 in the controls (P less than 0.001) and was negatively correlated with antiplasmin activity. Thirteen patients had areas of lysis equal to or inferior to the minimal lysis observed in the controls. No correlation was found between antiplasmin activity and serum fibrin-fibrinogen related antigen titres, the presence or absence of disseminated intravascular coagulation, or the causative disease.
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73
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Abstract
Baxic clotting mechanisms are reviewed. The clinical and laboratory aspects of disseminated intravascular coagulation and fibrinolysis are discussed, and an approach is suggested to those problems encountered by the urologist.
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74
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75
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76
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77
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78
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Astedt B, Liedholm P. Tranexamic acid and fibrinolytic activity of the vessel wall. EXPERIENTIA 1974; 30:776-7. [PMID: 4847668 DOI: 10.1007/bf01924181] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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79
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Jona JZ, Kwaan HC, Bjelan M, Raffensperger JG. Disseminated intravascular coagulation after excision of giant hemangioma. Am J Surg 1974; 127:588-92. [PMID: 4545017 DOI: 10.1016/0002-9610(74)90323-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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80
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Sonntag VK, Stein BM. Arteriopathic complications during treatment of subarachnoid hemorrhage with epsilon-aminocaproic acid. J Neurosurg 1974; 40:480-5. [PMID: 4814379 DOI: 10.3171/jns.1974.40.4.0480] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
✓ A review of arteriopathic complications in three of seven patients receiving epsilon-aminocaproic acid (EACA) is presented. All seven patients with subarachnoid hemorrhage due to ruptured aneurysm were receiving EACA in the presurgical treatment period. Each of the three patients showed cerebral arteriographic changes resembling arteritis or intravascular thrombosis, and a deteriorating clinical course.
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81
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82
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83
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Coggins JT, Allen TD. Insoluble fibrin clots within the urinary tract as a consequence of epsilon aminocaprioic acid therapy. J Urol 1972; 107:647-9. [PMID: 4259228 DOI: 10.1016/s0022-5347(17)61103-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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84
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85
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86
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Midell AI, Hallman GL, Bloodwell RD, Beall AC, Yashar JJ, Cooley DA. Epsilon-aminocaproic acid for bleeding after cardiopulmonary bypass. Ann Thorac Surg 1971; 11:577-82. [PMID: 5579106 DOI: 10.1016/s0003-4975(10)65076-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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87
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88
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Gralnick HR. Epsilon-aminocaproic acid in preoperative correction of haemostatic defect in cyanotic congenital heart-disease. Lancet 1970; 1:1204-5. [PMID: 4192381 DOI: 10.1016/s0140-6736(70)91789-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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89
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Brain MC, Azzopardi JG, Baker LR, Pineo GF, Roberts PD, Dacie JV. Microangiopathic haemolytic anaemia and mucin-forming adenocarcinoma. Br J Haematol 1970; 18:183-93. [PMID: 5439525 DOI: 10.1111/j.1365-2141.1970.tb01433.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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90
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