Is tranexamic acid (TXA) recommended for treating brain bleeds?

From the Guidelines

Tranexamic acid (TXA) should be considered for use in patients with traumatic brain injury and bleeding, particularly when administered within 3 hours of injury, as it may reduce head-injury-related mortality in patients with mild to moderate TBI, as suggested by the CRASH-3 trial 1. The use of TXA in brain bleeds is a topic of ongoing debate, with some studies suggesting a potential benefit in reducing mortality and hematoma expansion, while others have found no significant difference in outcomes.

• The CRASH-3 trial, a large randomized controlled trial, found that TXA reduced head-injury-related death in patients with mild and moderate head injury, but not in those with severe head injury 1.
• The European guideline on management of major bleeding and coagulopathy following trauma recommends the use of TXA in trauma patients who are bleeding or at risk of significant bleeding, as soon as possible and within 3 hours after injury 1.
• However, other studies have raised questions about the effectiveness of TXA in brain bleeds, and the potential risks of thrombotic complications must be weighed against any potential benefits 1. The current management of brain bleeds focuses on blood pressure control, reversal of anticoagulation if applicable, neurosurgical intervention when indicated, and supportive care in a neurocritical care setting.
• TXA may be considered as an adjunctive treatment in patients with traumatic brain injury and bleeding, particularly when administered early and in accordance with established guidelines 1. It is essential to carefully evaluate the individual patient's risk-benefit profile and consider the latest evidence and guidelines when making treatment decisions regarding the use of TXA in brain bleeds.

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.

• Tranexamic acid (TXA) is contraindicated in patients with subarachnoid hemorrhage, a type of brain bleed.
• The use of TXA in brain bleeds is not recommended due to the risk of cerebral edema and cerebral infarction 2.

From the Research

Tranexamic Acid (TXA) for Brain Bleeds

• TXA is an antifibrinolytic agent that has been studied for its potential in managing brain bleeds, including traumatic brain injury and nontraumatic intracranial hemorrhage 3, 4, 5, 6, 7.
• The evidence suggests that TXA may be effective in reducing blood loss and transfusion requirements in certain neurosurgical applications, including brain tumor surgery and aneurysmal subarachnoid hemorrhage 3.
• However, the use of TXA in traumatic brain injury has yielded mixed results, with some studies suggesting a potential benefit in reducing head injury-related mortality, while others have found no significant difference in outcomes 4, 5, 6, 7.
• A systematic review and meta-analysis found that TXA did not significantly reduce all-cause mortality in traumatic brain injury patients, but may have a favorable safety profile 7.
• Another study found that TXA may prevent rebleeding in aneurysmal subarachnoid hemorrhage, but did not lead to improved outcomes or reduced mortality 4.
• The optimal dosing and timing of TXA administration in brain bleed patients is still unclear and requires further study 3, 6.

Key Findings

• TXA may be effective in reducing blood loss and transfusion requirements in certain neurosurgical applications 3.
• TXA may have a favorable safety profile in traumatic brain injury patients, but its efficacy is still unclear 7.
• The use of TXA in nontraumatic intracranial hemorrhage may reduce hematoma expansion, but does not appear to improve functional outcomes 4.
• Further studies are needed to determine the optimal dosing and timing of TXA administration in brain bleed patients, as well as to clarify its efficacy and safety in different patient populations 3, 4, 5, 6, 7.