What is the role of Tranexamic acid (TXA) in the management of intracranial traumatic hemorrhage in a child?

From the Guidelines

Tranexamic acid (TXA) is recommended for children with intracranial traumatic hemorrhage, administered as soon as possible within 3 hours of injury, with a dosing regimen of 1 g bolus followed by 1 g 8 h infusion i.v., as it has been shown to reduce head injury-related death in mild and moderate head injury 1. The use of TXA in pediatric traumatic brain injury is supported by the results of the CRASH-3 trial, which demonstrated a reduction in head injury-related death in patients treated within 3 hours of injury 1.

Key Points

• The dosing regimen for TXA in children with intracranial traumatic hemorrhage is 1 g bolus followed by 1 g 8 h infusion i.v. 1.
• TXA should be administered as soon as possible within 3 hours of injury to maximize its effectiveness 1.
• The medication works by inhibiting fibrinolysis, thereby stabilizing blood clots and reducing hemorrhage expansion 1.
• TXA is particularly beneficial in the acute phase of traumatic brain injury when the risk of hematoma expansion is highest 1.

Considerations

• Contraindications for TXA include hypersensitivity to the medication, active thromboembolic disease, subarachnoid hemorrhage, and severe renal impairment.
• Potential side effects of TXA include nausea, vomiting, hypotension with rapid infusion, and rarely seizures.
• While administering TXA, standard management of pediatric traumatic brain injury should continue, including maintaining adequate cerebral perfusion pressure, preventing secondary brain injury, and neurosurgical intervention when indicated.

Evidence Summary

• The CRASH-3 trial demonstrated a reduction in head injury-related death in patients treated with TXA within 3 hours of injury 1.
• The trial also showed that early treatment with TXA reduced death in mild and moderate head injury, but not in severe head injury 1.
• TXA was found to be highly cost-effective for mild and moderate head injury and in patients in which both pupils reacted 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.

The role of Tranexamic acid (TXA) in the management of intracranial traumatic hemorrhage in a child is contraindicated due to the risk of cerebral edema and cerebral infarction, as stated in the drug labels 2 and 2. Key points include:

• Tranexamic acid is not recommended for use in patients with subarachnoid hemorrhage
• The risk of cerebral edema and cerebral infarction is a concern with the use of tranexamic acid in such patients.

From the Research

Role of Tranexamic Acid in Intracranial Traumatic Hemorrhage in Children

• The current evidence on the use of tranexamic acid (TXA) in the management of intracranial traumatic hemorrhage in children is limited, and most studies have focused on adult populations 3, 4, 5, 6, 7.
• However, the available studies suggest that TXA may reduce the incidence of hematoma expansion and the volume of hemorrhagic lesions in patients with traumatic brain injury (TBI) 4, 6, 7.
• A study published in 2013 found that TXA may reduce progressive intracranial hemorrhage (PIH) in patients with TBI, but the difference was not statistically significant 3.
• Another study published in 2021 found that early administration of TXA was associated with better outcomes in terms of hematoma expansion and growth of hemorrhagic lesions, but did not significantly reduce mortality or poor outcomes 4.
• A review of the current literature on the use of TXA in the management of TBI, nontraumatic intracranial hemorrhage, and aneurysmal subarachnoid hemorrhage found that TXA has not been shown to improve functional outcomes and cannot be routinely recommended 5.
• Two randomized controlled trials published in 2017 and 2024 found that TXA reduced the extent of ICH growth and improved clinical outcomes in patients with TBI 6, 7.
• The studies suggest that TXA may be beneficial in reducing the progression of hematoma and improving clinical outcomes in patients with TBI, but larger studies are needed to confirm these findings and to determine the optimal dosage and timing of TXA administration 3, 4, 5, 6, 7.

Key Findings

• TXA may reduce the incidence of hematoma expansion and the volume of hemorrhagic lesions in patients with TBI 4, 6, 7.
• TXA may improve clinical outcomes in patients with TBI, but the evidence is limited and inconclusive 3, 5, 6, 7.
• Larger studies are needed to confirm the findings and to determine the optimal dosage and timing of TXA administration 3, 4, 5, 6, 7.

Study Limitations

• Most studies have focused on adult populations, and there is limited evidence on the use of TXA in children with intracranial traumatic hemorrhage 3, 4, 5, 6, 7.
• The studies have used different dosages and timing of TXA administration, which may affect the outcomes 3, 4, 5, 6, 7.
• The evidence is limited by the small sample sizes and the variability in the study designs and outcomes 3, 4, 5, 6, 7.