Is tranexamic acid (TXA) safe to use in patients with subarachnoid hemorrhage (SAH)?

From the Guidelines

Tranexamic acid (TXA) is not recommended for use in patients with subarachnoid hemorrhage (SAH) due to the potential risk of cerebral ischemia and thromboembolic complications, as suggested by the most recent evidence 1. The use of TXA in SAH patients has been a topic of debate, with some studies suggesting a potential benefit in reducing rebleeding, but this benefit is often offset by the increased risk of cerebral ischemia and thromboembolic events.

• The ULTRA study, mentioned in 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.
• Other studies, such as 1 and 1, also highlight the potential risks associated with TXA use in SAH patients, including cerebral edema and cerebral infarction.
• The European Society of Intensive Care Medicine guideline 1 makes no recommendation regarding the use of TXA in critically ill patients with subarachnoid hemorrhage, citing low certainty evidence. In clinical practice, the decision to use TXA in SAH patients should be individualized, taking into account the patient's specific risk factors, timing of definitive aneurysm treatment, and the balance between rebleeding and ischemic risks.
• Alternative strategies to prevent rebleeding in SAH focus on early aneurysm securing through surgical clipping or endovascular coiling, along with careful blood pressure management.
• Patients receiving TXA should be closely monitored for signs of cerebral ischemia, deep vein thrombosis, pulmonary embolism, and other thromboembolic events, as suggested by 1 and 1.

From the FDA Drug Label

• In patients with subarachnoid hemorrhage, due to risk of cerebral edema and cerebral infarction. (4) • In patients with subarachnoid hemorrhage. Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by Tranexamic acid in such patients. • In patients with subarachnoid hemorrhage, due to risk of cerebral edema and cerebral infarction. (4)

Tranexamic acid is contraindicated in patients with subarachnoid hemorrhage (SAH) due to the risk of cerebral edema and cerebral infarction 2, 2, 2.

From the Research

Safety and Efficacy of Tranexamic Acid in SAH

• Tranexamic acid (TXA) has been shown to reduce rebleeding after aneurysmal subarachnoid hemorrhage (SAH) 3, 4, 5, 6.
• However, its effect on mortality and clinical outcomes is still controversial, with some studies suggesting no significant improvement in overall mortality or neurological outcome 3, 4, 5, 6.
• TXA may be associated with an increased risk of hydrocephalus 4, but no significant differences in other adverse events, such as cerebral ischemia, have been reported 3, 5.

Clinical Use of Tranexamic Acid in SAH

• The current evidence does not support the routine use of TXA in patients with SAH 3, 4.
• Additional higher-quality studies are needed to further assess the effect of TXA on patients with SAH 3.
• TXA may be effective in reducing the risk of rebleeding in patients with SAH, but its benefits in overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus are not well established 5, 6.

Adverse Events and Safety

• No significant adverse events, such as thromboembolic complications, have been reported with the use of TXA in patients with SAH 7.
• The safety profile of TXA in patients with SAH appears to be favorable, with no significant differences in adverse events compared to control treatments 3, 5.