Can Tranexamic Acid (TXA) be used in intracranial hemorrhage?

Tranexamic Acid in Intracranial Hemorrhage

Tranexamic acid (TXA) is contraindicated in patients with subarachnoid hemorrhage due to risk of cerebral edema and cerebral infarction, and should not be routinely used in other types of intracranial hemorrhage as it has not demonstrated significant improvement in mortality or functional outcomes. 1

Types of Intracranial Hemorrhage and TXA Use

Subarachnoid Hemorrhage (SAH)

• TXA is explicitly contraindicated in SAH according to FDA labeling 1
• Despite reducing rebleeding risk (RR 0.6,95% CI 0.44-0.8), this benefit is offset by an increased risk of stroke (RR 1.29,95% CI 1.01-1.67) 2, 3
• No significant improvement in mortality (RR 1.01,95% CI 0.88-1.16) or functional outcomes (RR 1.05,95% CI 0.95-1.15) 2
• The European Society of Intensive Care Medicine makes no recommendation regarding TXA use in SAH, citing low certainty evidence 2, 4

Non-traumatic Intracranial Hemorrhage (ICH)

• No recommendation for or against TXA use in non-traumatic ICH (moderate certainty evidence) 2
• TXA shows no significant effect on:
  • Mortality (RR 1.02,95% CI 0.88-1.19) 2
  • Poor functional outcomes (RR 0.98,95% CI 0.93-1.04) 2
  • Other outcomes including stroke, MI, VTE, seizures, and length of stay 2
• While TXA may reduce hematoma growth in ICH, this has not translated to improved clinical outcomes 5, 6

Traumatic Brain Injury (TBI)

• TXA may reduce progressive hemorrhage in TBI patients with reactive pupils at baseline 7
• The European guideline on management of major bleeding recommends TXA administration within 3 hours of injury in trauma patients who are bleeding or at risk of significant bleeding 2
• However, more recent evidence suggests potential harm in severely injured TBI patients 6

Clinical Decision Algorithm

1. For subarachnoid hemorrhage:

   • Do NOT use TXA (FDA contraindication) 1
   • Focus on early aneurysm repair as the definitive treatment 3
   • Control blood pressure (target systolic BP <160 mmHg) 4

2. For non-traumatic intracranial hemorrhage:

   • TXA is not recommended for routine use 2
   • Focus on standard management protocols including blood pressure control, reversal of coagulopathy if present, and neurosurgical consultation 2

3. For traumatic brain injury:

   • TXA may be considered within 3 hours of injury in bleeding patients 2
   • Use with caution in severe TBI (GCS 3-8) as benefit is less clear 6, 7
   • Standard dosing: 1g loading dose over 10 minutes, followed by 1g infusion over 8 hours 2

Important Caveats and Pitfalls

• Timing is critical: If TXA is used in trauma, it should be administered as soon as possible, ideally within 3 hours of injury 2
• Contraindication in SAH: Never use TXA in subarachnoid hemorrhage due to increased risk of cerebral edema and infarction 1
• Beware of active intravascular clotting: TXA is contraindicated in patients with active intravascular clotting 1
• Limited evidence of benefit: Despite theoretical benefits in reducing hemorrhage expansion, TXA has not consistently demonstrated improvement in mortality or functional outcomes in intracranial hemorrhage 2, 6
• Monitoring for adverse effects: If TXA is used, monitor for thromboembolic events, seizures, and visual disturbances 1

In conclusion, while TXA has theoretical benefits in reducing hemorrhage expansion, its use in intracranial hemorrhage remains controversial with limited evidence of improved clinical outcomes. It is explicitly contraindicated in subarachnoid hemorrhage and should not be routinely used in other types of intracranial hemorrhage outside of specific clinical trial protocols.