From the Guidelines
Tranexamic acid is not currently recommended for routine use in stroke management. The standard treatment for ischemic stroke remains prompt administration of intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, followed by mechanical thrombectomy in eligible patients with large vessel occlusion 1. For hemorrhagic stroke, tranexamic acid has been studied in clinical trials, but results have not shown significant improvement in functional outcomes despite modest reduction in hematoma expansion.
Key Considerations
- The use of tPA is associated with improved outcomes for a broad spectrum of patients who can be treated within 3 hours of stroke onset, with earlier treatment being more likely to result in a favorable outcome 1.
- The major risk of tPA treatment is symptomatic brain hemorrhage, which occurred in 6.4% of patients treated with tPA and 0.6% of patients given placebo 1.
- Current stroke management focuses on rapid diagnosis, appropriate reperfusion therapy for ischemic stroke, blood pressure control for hemorrhagic stroke, and supportive care including management of swallowing, prevention of complications, and early rehabilitation.
Mechanism and Potential Risks
- Tranexamic acid works by inhibiting fibrinolysis and stabilizing blood clots, which could theoretically be harmful in ischemic stroke by promoting thrombosis.
- The presence of edema or mass effect on baseline CT scan is associated with higher risk of symptomatic intracranial hemorrhage, but early CT evidence of edema is not associated with adverse outcome 1.
Future Directions
- Future research may better define specific stroke subgroups that might benefit from tranexamic acid, but at present, it remains experimental rather than standard care.
- The likelihood of favorable outcome is also affected by the severity of deficits and the patient’s age, with patients with mild to moderate strokes and persons younger than 75 years of age having the greatest potential for a favorable response to treatment 1.
From the FDA Drug Label
4 CONTRAINDICATIONS
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.
The role of Tranexamic acid (TXA) in the management of stroke is that it is contraindicated in patients with subarachnoid hemorrhage, as it may cause cerebral edema and cerebral infarction 2.
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 3.
- Studies suggest a potential role for TXA in the management of acute intracranial hemorrhage, with some indicating a mortality benefit 3, 4.
- The use of TXA in patients with intracerebral hemorrhage has been explored, with some case reports showing improvement in clinical outcomes 4, 5.
Efficacy of Tranexamic Acid in Reducing Hematoma Expansion
- A randomized, placebo-controlled trial (TICH-2) found that TXA did not significantly reduce hematoma expansion or improve functional outcomes in patients with intracerebral hemorrhage 6.
- Another trial (TRAIGE) found that TXA did not significantly prevent intracerebral hemorrhage growth in patients susceptible to hemorrhage expansion 7.
- However, some studies suggest that TXA may reduce early deaths and serious adverse events in patients with intracerebral hemorrhage 6.
Safety and Potential Risks
- Theoretical risks of thrombotic events following TXA use exist, but large clinical trials suggest this risk remains small 3.
- TXA is generally considered safe and well-tolerated, with few serious adverse events reported in clinical trials 6, 7.
- Further research is needed to fully assess the safety and efficacy of TXA in the management of stroke, particularly in larger randomized trials 4, 6, 7.