From the Guidelines
Tranexamic acid (TXA) is not recommended for routine use in medically managed subarachnoid hemorrhage (SAH) due to the lack of clear benefit in reducing morbidity and mortality, and the potential increased risk of thromboembolic complications, as suggested by the most recent and highest quality study 1. The use of TXA in SAH has been evaluated in several studies, with the most recent and highest quality study published in 2021 1. This study found that TXA did not reduce mortality or poor functional outcome, but did reduce the risk of rebleeding, which was offset by an increased risk of stroke.
- The standard dosing regimen for TXA is 1 gram IV every 6 hours for up to 72 hours or until the aneurysm is secured, but this should not be used routinely in medically managed SAH.
- TXA works by inhibiting fibrinolysis, which helps stabilize the clot at the site of aneurysmal rupture and reduces the risk of early rebleeding.
- However, TXA should be used with caution as it may increase the risk of thromboembolic complications such as deep vein thrombosis or pulmonary embolism, and therefore, appropriate DVT prophylaxis should be considered.
- The 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage from the American Heart Association/American Stroke Association does not provide specific recommendations for the use of TXA in medically managed SAH 1.
- Other studies have also evaluated the use of TXA in SAH, but the most recent and highest quality study should be prioritized when making a recommendation 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.
Tranexamic acid (TXA) is contraindicated for medically managed Subarachnoid Hemorrhage (SAH) due to the risk of cerebral edema and cerebral infarction 2, 2.
From the Research
Tranexamic Acid (TXA) for Medically Managed Subarachnoid Hemorrhage (SAH)
- TXA is a synthetic antifibrinolytic agent that inhibits plasminogen activation, thereby reducing bleeding 3
- The use of TXA in aneurysmal SAH has been shown to reduce the risk of rebleeding, with a meta-analysis of six studies involving 2990 patients demonstrating a significant reduction in rebleeding risk (OR 0.54,95% CI 0.43-0.68; p < 0.00001) 3
- Another meta-analysis of five randomized controlled trials and 2359 patients also found that TXA was associated with a significantly reduced risk of rebleeding (OR = 0.62; 95% CI = 0.41 to 0.93; P = 0.02) 4
- A systematic review and meta-analysis of 13 studies with a total of 2991 patients found that TXA could significantly cut the risk of rebleeding (RR 0.56,95% CI 0.44 to 0.72) and mortality from rebleeding (RR 0.60,95% CI 0.39 to 0.92, p = 0.02) 5
Efficacy and Safety of TXA in SAH
- The efficacy of TXA in reducing mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus is not well established, with most studies showing no significant difference between TXA and control groups 3, 4, 5
- TXA has been shown to be safe, with no significant adverse events reported in the majority of studies 3, 5
- The American Heart Association/American Stroke Association and the Neurocritical Care Society have outlined best practices for the management of patients with SAH, including the use of TXA, but the role of TXA in improving patient outcomes remains understudied 6, 7
Clinical Implications
- TXA may be effective in reducing the risk of rebleeding in patients with SAH, but its use should be carefully considered in the context of individual patient needs and circumstances 3, 4, 5
- Further research is needed to clarify the role of TXA in improving patient outcomes and to establish its long-term safety and efficacy 3, 6, 7