Is tranexamic acid (TXA) used to treat hemorrhagic stroke?

Tranexamic Acid for Hemorrhagic Stroke

Tranexamic acid (TXA) is not currently recommended as standard treatment for spontaneous intracerebral hemorrhage (ICH) as clinical trials have not consistently demonstrated improved functional outcomes or mortality despite showing reductions in hematoma expansion. 1, 2

Current Evidence on TXA in Hemorrhagic Stroke

• Clinical trials have shown that TXA can reduce hematoma expansion in ICH, but this has not consistently translated to improved clinical outcomes or reduced mortality 1, 3
• The TICH-2 randomized controlled trial (n=2325) found no statistically significant difference in functional status at 90 days between TXA and placebo groups, despite modest reductions in early death and hematoma expansion 2
• Meta-analyses indicate TXA reduces rebleeding and hematoma expansion but does not improve mortality or functional outcomes in spontaneous ICH 3
• While TXA appears to be safe with no significant increase in single thromboembolic events, there may be an increased risk of combined ischemic events 3

Specific Clinical Scenarios Where TXA May Be Considered

• TXA may be beneficial when administered very early after ICH onset (within 3-6 hours), particularly in hyperacute presentations 4, 5
• There is ongoing investigation of TXA use in specific ICH populations, such as:
  • NOAC-associated ICH (TICH-NOAC trial) 4
  • Hyperacute ICH presentations, including use in mobile stroke units 1
  • Antiplatelet-associated ICH 1

Timing Considerations

• If TXA is used, early administration is crucial - ideally within 3-6 hours of symptom onset 6, 4
• The TICH-NOAC trial suggested a potential interaction with onset-to-treatment time, favoring TXA when administered within 6 hours of symptom onset 4
• Administration of TXA after 3 hours post-injury in trauma may increase risk of death due to bleeding 6

Dosing Considerations

• Standard dosing used in most ICH trials: 1g loading dose over 10 minutes, followed by 1g infusion over 8 hours 6, 2
• Higher doses of TXA are associated with increased risk of seizures 6

Safety Considerations

• TXA appears generally safe in ICH patients with no significant increase in:
  • Hydrocephalus 3
  • Deep vein thrombosis 3
  • Pulmonary embolism 3
• However, there may be an increased risk of combined ischemic events 3
• In the TICH-2 trial, fewer patients experienced serious adverse events with TXA compared to placebo 2

Special Situations

• TXA has been reported as a case-based treatment for intravenous rtPA-associated hemorrhage in ischemic stroke patients 1
• Case reports suggest potential benefit in post-procedural ICH, such as after coronary procedures 7

Future Directions

• Ongoing trials are evaluating TXA in specific ICH populations:
  • ICH associated with direct oral anticoagulants 1, 4
  • Hyperacute ICH presentations 1
  • Antiplatelet-associated ICH 1
• Future research should focus on early treatment and identifying which patients are most likely to benefit from hemostatic therapy 2

Despite showing promise in reducing hematoma expansion, the lack of demonstrated improvement in functional outcomes and mortality currently limits the routine use of TXA in spontaneous ICH. Clinicians should consider the potential benefits and risks on a case-by-case basis while awaiting results from ongoing trials that may better define its role.