From the Guidelines
Tranexamic acid (TXA) is not recommended for routine use in patients with subarachnoid hemorrhage (SAH) due to the lack of improvement in overall outcomes and the increased risk of cerebral ischemia and thrombotic complications. The most recent and highest quality study, the ULTRA trial 1, failed to show improvement in outcomes at 6 months in patients receiving early tranexamic acid, leading to the conclusion that antifibrinolytic therapy is not recommended.
While TXA can reduce the risk of rebleeding in SAH by inhibiting fibrinolysis and stabilizing blood clots, this benefit is offset by an increased risk of stroke and other thrombotic complications, as demonstrated in previous trials 1. The traditional dosing of 1 gram IV every 6 hours has not been shown to improve overall outcomes compared to placebo.
Current management of SAH instead focuses on:
- Early aneurysm securing (via surgical clipping or endovascular coiling)
- Blood pressure control, with optimal early BP target remaining unclear, but avoiding BP variability and hypotension 1
- Nimodipine for vasospasm prevention
- Supportive care
In very specific circumstances, such as when there will be an unavoidable delay in definitive aneurysm treatment, some clinicians might consider short-term TXA use, but this remains controversial and is not standard practice. The increased risk of delayed cerebral ischemia, hydrocephalus, and deep vein thrombosis outweighs the potential benefit of reduced rebleeding, making TXA not a recommended treatment for SAH 1.
From the FDA Drug Label
In patients with subarachnoid hemorrhage, due to risk of cerebral edema and cerebral infarction. Tranexamic acid is contraindicated: In patients with subarachnoid hemorrhage. Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by tranexamic acid in such patients.
Tranexamic acid is not recommended for patients with subarachnoid hemorrhage, as it is contraindicated due to the risk of cerebral edema and cerebral infarction 2, 2.
From the Research
Tranexamic Acid for Subarachnoid Hemorrhage
- Tranexamic acid (TXA) has been shown to reduce rebleeding after aneurysmal subarachnoid hemorrhage 3, 4, 5, 6, 7
- However, whether TXA can reduce mortality and improve clinical outcomes is controversial 3, 4, 5, 6, 7
- A systematic review and meta-analysis of randomized controlled trials found that TXA had no significant effect on all-cause mortality or poor functional outcome compared with the control group 3
- Another study found that TXA effectively reduces the risk of rebleeding in SAH patients, but does not significantly alter mortality or the incidence of thromboembolic complications 4
- A meta-analysis of 13 RCTs found that TXA significantly reduced rebleeding rates, but did not affect mortality or good clinical outcomes 5
- TXA use was associated with increased occurrence of hydrocephalus, but not delayed cerebral ischemia 5
- Subgroup analyses suggested greater rebleeding reduction with longer TXA administration and in more recent studies 5
- A systematic review and meta-analysis of 5 RCTs found that TXA was associated with significantly reduced risk of rebleeding, but had no influence on mortality, poor outcome, hydrocephalus, or delayed cerebral ischemia 6
- Another study found that TXA significantly reduces the incidence of rebleeding and mortality from rebleeding, but does not improve overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus 7
Recommendations
- At present, routine use of tranexamic acid after subarachnoid hemorrhage cannot be recommended 3
- For a patient with subarachnoid hemorrhage, it is essential to obliterate the aneurysm as early as possible 3
- Additional higher-quality studies are needed to further assess the effect of tranexamic acid on patients with subarachnoid hemorrhage 3, 4, 5