Is tranexamic acid (TXA) recommended as a first-line treatment to stop a brain bleed?

From the Guidelines

Tranexamic acid (TXA) is not recommended as a first-line treatment to stop an active brain bleed. The primary management of brain hemorrhage typically involves neurosurgical intervention, blood pressure control, reversal of anticoagulation if applicable, and supportive critical care. While TXA is an antifibrinolytic agent that helps prevent blood clot breakdown and is effective in trauma-related bleeding elsewhere in the body, its role in intracranial hemorrhage remains controversial.

Key Points

• Clinical trials investigating TXA in spontaneous intracerebral hemorrhage (such as the TICH-2 trial) have not demonstrated clear benefits in improving survival or functional outcomes 1.
• TXA may be considered in specific circumstances, such as when the brain bleed is associated with trauma or when other treatments have failed, but it is not a standard first-line approach.
• The medication works by inhibiting plasminogen activation, which prevents the breakdown of fibrin in blood clots, but this mechanism has not translated to consistent clinical benefit in brain hemorrhage cases.
• Treatment decisions for brain bleeds should be made rapidly by neurosurgical and neurological specialists based on the specific cause, location, and severity of the hemorrhage.

Considerations

• The European guideline on management of major bleeding and coagulopathy following trauma recommends TXA administration to the trauma patient who is bleeding or at risk of significant bleeding as soon as possible, but this is in the context of trauma-related bleeding, not specifically brain bleeds 1.
• The effects of TXA appear mixed, with a decreased risk of rebleeding, and a similar magnitude of increased stroke, but overall, there appears to be little impact upon mortality and the risk of poor functional outcome 1.

From the FDA Drug Label

In patients with subarachnoid hemorrhage. Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by tranexamic acid in such patients. The FDA drug label does not answer the question.

From the Research

Tranexamic Acid (TXA) in Brain Bleed Treatment

• Tranexamic acid (TXA) is a measure indicated to reduce bleeding and the need for volume replacement in neurosurgery 2.
• The use of TXA can considerably reduce the risk of rebleeding in a ruptured intracranial aneurysm, but there is weak evidence regarding its influence on mortality reduction 2.
• TXA can significantly reduce blood loss in a wide range of surgical procedures and improve survival rates in obstetric and trauma patients with severe bleeding 3.
• In patients with intracranial haemorrhage, TXA can significantly reduce the risk of hematoma growth and decrease the risk of hydrocephalus and rebleeding 4.

Efficacy and Safety of TXA

• The efficacy and safety of TXA for intracranial haemorrhage remain controversial, with some studies showing benefits and others raising concerns about adverse effects 3, 4.
• Early treatment with TXA (within 1-3 hours of injury) can significantly reduce the risk of death due to bleeding in trauma patients 5.
• TXA may be used in combination with other agents, such as recombinant activated factor VII (rFVIIa), for reversal of life-threatening hemorrhage in bleeding patients with exposure to novel factor XIa inhibitors 6.

Clinical Use of TXA

• TXA is generally well tolerated, and most adverse reactions are considered mild or moderate 3.
• The administration of high doses of TXA has been associated with seizures and other adverse effects 2, 3.
• The optimal dosage, route, and interval of administration of TXA are still being evaluated and reviewed to improve its safety and effectiveness in treating intracranial hemorrhage and bleeding in various surgical procedures 3.