Recommended Dose of Tranexamic Acid for Stroke
Tranexamic acid (TXA) for stroke should be administered at a loading dose of 1 g intravenously over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours, and should be given as soon as possible and within 3 hours of symptom onset. 1, 2, 3
Dosing Recommendations by Stroke Type
Hemorrhagic Stroke
- For intracerebral hemorrhage (ICH), the recommended dose is 1 g IV bolus over 10 minutes followed by 1 g IV infusion over 8 hours 4, 5
- Administration should occur within 8 hours of symptom onset, though earlier treatment (within 3 hours) is associated with better outcomes 4, 5
- The TICH-2 trial showed modest reductions in early death and hematoma expansion with this dosing regimen, though no significant difference in functional status at 90 days 5
Ischemic Stroke
- Current guidelines do not specifically recommend TXA for ischemic stroke 1
- For ischemic stroke, recombinant tissue plasminogen activator (rtPA) remains the standard treatment at 0.9 mg/kg (maximum 90 mg) within 3-4.5 hours of symptom onset 1
- TXA is not indicated as a primary treatment for ischemic stroke as it has antifibrinolytic properties that could theoretically counteract thrombolytic therapy 1
Timing Considerations
- Effectiveness of TXA decreases by approximately 10% for every 15-minute delay in administration 2, 3
- Administration should occur as soon as possible after onset of bleeding 1, 3
- Administration after 3 hours post-injury may increase risk of death due to bleeding 3
- Pre-hospital administration should be considered to ensure early treatment 3
Route of Administration
- Intravenous administration is the recommended and evidence-based route 1, 2
- Current guidelines do not include specific recommendations for intramuscular dosing of TXA 2
- The European guidelines explicitly state their recommendations apply to intravenous administration only 2
Safety Considerations
- TXA is generally well-tolerated with no increase in thromboembolic events reported in major trials 4, 5
- Fewer serious adverse events were observed with TXA compared to placebo in the TICH-2 trial 5
- Higher doses of TXA are associated with increased risk of seizures, particularly in cardiac surgery patients 3
- Blood pressure should be monitored and controlled during administration 1
Special Populations
- For traumatic brain injury, TXA has shown benefit in reducing head injury-related death when administered within 3 hours, particularly in mild to moderate TBI 3
- Early treatment with TXA showed reduction in mortality in mild and moderate head injury but not in severe head injury 1
Common Pitfalls
- Delaying administration beyond 3 hours significantly reduces effectiveness 3
- Using TXA in ischemic stroke patients who are candidates for thrombolytic therapy could theoretically counteract the beneficial effects of thrombolytics 1
- Limiting TXA use only to patients with diagnosed hyperfibrinolysis could result in missed opportunities to prevent mortality 6
- Older studies using different dosing regimens (such as 6g daily) may not reflect current evidence-based recommendations 7