Tranexamic Acid in Intracerebral Hemorrhage
Tranexamic acid should NOT be used routinely in non-traumatic intracerebral hemorrhage, as it reduces hematoma expansion but does not improve functional outcomes or mortality at 90 days. 1
Guideline Position on Non-Traumatic ICH
The American Heart Association/American Stroke Association and European Stroke Organisation explicitly do not recommend routine use of tranexamic acid for spontaneous ICH, including hypertensive ICH, outside of clinical trials. 1 This recommendation stands despite evidence that TXA reduces hematoma expansion (OR 0.79,95% CI 0.67-0.93) 2, because:
- No improvement in functional outcomes (RR 0.98,95% CI 0.93-1.04) 1
- No reduction in 90-day mortality (RR 1.02,95% CI 0.88-1.19) 1
- No decrease in need for neurosurgical intervention (OR 0.893,95% CI 0.619-1.289) 3
The disconnect between radiographic improvement and clinical outcomes occurs because many factors beyond hematoma expansion determine outcome—including baseline hemorrhage volume, level of consciousness, intraventricular hemorrhage, age, and comorbidities. 1
Critical Timing Considerations If TXA Is Used
If TXA is considered in select cases (such as ongoing clinical trials), timing is absolutely critical:
- Treatment within 1 hour shows 65% lower 30-day mortality (HR 0.35,95% CI 0.19-0.65) 4
- Benefit decreases by 10% every 15 minutes of delay 4
- Treatment within 4.5 hours reduces hematoma expansion in high-risk populations (OR 0.823,95% CI 0.690-0.980) 5
- Treatment after 3 hours may actually increase mortality risk and should be avoided 6
Patient Selection Pitfalls
Avoid treating patients with very large hemorrhages, as reduction in further bleeding has minimal impact when baseline volume is already massive. 1 The TICH-2 trial's pragmatic inclusion criteria led to enrollment of heterogeneous patients, including those with very large strokes who were unlikely to benefit. 7
Consider TXA only in mild-to-moderate ICH patients with CT markers of hematoma expansion (spot sign, black hole sign, or blend sign) who can be treated within 1-4.5 hours. 4, 5
Standard Dosing Protocol
When administered, use: 1g IV loading dose over 10 minutes, followed by 1g infusion over 8 hours. 1, 4, 6
Safety Profile
TXA has a favorable safety profile in ICH:
- No significant increase in thromboembolic events across ICH studies 1, 7
- Fewer serious adverse events with TXA than placebo in TICH-2 (45% vs 48% by day 90) 4
- Reduced early mortality by day 7 (aOR 0.73,95% CI 0.53-0.99), though this does not translate to 90-day survival benefit 7
Contraindications
Do not use TXA in patients with:
- Active disseminated intravascular coagulation 1
- Massive hematuria or renal insufficiency (use with caution) 1
Traumatic Brain Injury Context (Different Recommendation)
In contrast to non-traumatic ICH, TXA IS recommended for mild-to-moderate traumatic brain injury when given within 3 hours, reducing head injury-related death by 22% (RR 0.78,95% CI 0.64-0.95). 6 This represents a fundamentally different pathophysiology and treatment paradigm.