From the Guidelines
Tranexamic acid is not currently recommended for routine use in stroke management. For ischemic stroke, the standard treatments remain intravenous thrombolysis with alteplase (0.9 mg/kg, maximum 90 mg, with 10% given as bolus and remainder over 60 minutes) within 4.5 hours of symptom onset, and/or mechanical thrombectomy for large vessel occlusions within 24 hours. The use of intravenous rtPA is associated with improved outcomes for a broad spectrum of patients who can be treated within 3 hours of the last known well time before symptom onset and a mildly more selective spectrum of patients who can be treated between 3 and 4.5 hours of the last known well time 1.
For hemorrhagic stroke, tranexamic acid has been studied in clinical trials but failed to demonstrate significant improvement in functional outcomes despite reducing hematoma expansion in some patients. The theoretical benefit of tranexamic acid in hemorrhagic stroke is its antifibrinolytic properties that could limit bleeding by inhibiting plasmin-mediated clot breakdown. However, concerns exist about potential thromboembolic complications, especially in patients with vascular disease. Current stroke guidelines do not support tranexamic acid use outside clinical trials 1.
Some key points to consider in the management of stroke include:
- Blood pressure control
- Reversal of anticoagulation if applicable
- Neurosurgical evaluation These remain the cornerstones of hemorrhagic stroke management. Research is ongoing to identify specific patient subgroups who might benefit from tranexamic acid in acute stroke settings. The major risk of treatment with intravenous rtPA is symptomatic brain hemorrhage, which occurred in 6.4% of patients treated with rtPA and 0.6% of patients given placebo 1.
In terms of patient selection for intravenous rtPA, the likelihood of favorable outcome is affected by the severity of deficits and the patient’s age. Patients with mild to moderate strokes (NIHSS score <20) and persons younger than 75 years of age had the greatest potential for a favorable response to treatment 1.
From the Research
Role of Tranexamic Acid in Stroke Management
- Tranexamic acid (TXA) is an antifibrinolytic agent that may reduce acute hemorrhage through inhibition of plasminogen 2
- Studies suggest a potential role for TXA in the management of acute intracranial hemorrhage, with some trials showing a reduction in early deaths and serious adverse events 3, 4
- However, the evidence is not consistent, and some studies have found no significant difference in outcomes between TXA and placebo groups 3, 4
Mechanism of Action
- TXA works by competitively inhibiting the activation of plasminogen, which can help to prevent further bleeding in patients with intracranial hemorrhage 5
- This mechanism of action suggests that TXA may be useful in reversing thrombolytic therapy with tissue plasminogen activator (tPA) in patients who develop symptomatic intracranial hemorrhage 5
Safety and Efficacy
- A systematic review and meta-analysis found no association between intravenous TXA and increased risk of thromboembolic events, and suggested that TXA is safe for use in patients receiving neurological care 6
- However, the evidence is not yet conclusive, and larger studies are needed to fully assess the safety and efficacy of TXA in the management of stroke 3, 4
Clinical Applications
- TXA may be considered as an adjunct therapy in the management of acute, severe traumatic and nontraumatic hemorrhage, including intracranial hemorrhage 2
- Further research is needed to determine the optimal dosing and timing of TXA administration in patients with stroke, as well as its potential use in combination with other therapies 6