Can tranexamic acid be used in acute intracerebral or subarachnoid hemorrhage (brain bleeds) in a patient without active thrombotic disease, recent major surgery, or renal impairment?

Can Tranexamic Acid Be Used for Brain Bleeds?

Tranexamic acid can be used in traumatic brain injury but is contraindicated in subarachnoid hemorrhage and not routinely recommended for spontaneous intracerebral hemorrhage, as it reduces hematoma expansion without improving functional outcomes or mortality. 1, 2, 3

FDA Contraindication for Subarachnoid Hemorrhage

• Tranexamic acid is absolutely contraindicated in patients with subarachnoid hemorrhage due to risk of cerebral edema and cerebral infarction. 1
• This is a black-box level contraindication in the FDA labeling that supersedes any potential benefits. 1

Traumatic Brain Injury: Conditional Use

• In traumatic brain injury, tranexamic acid should be administered within 3 hours of injury, using 1g IV over 10 minutes followed by 1g over 8 hours. 3, 4, 5
• The benefit appears limited to mild-to-moderate TBI when given within 1 hour of symptom onset, potentially reducing head injury-related death. 2, 3
• Do not administer after 3 hours post-injury, as this may increase risk of death due to bleeding. 3, 4
• Patients with severe TBI (Glasgow Coma Score of 3 or bilateral unreactive pupils) are unlikely to benefit. 2

Spontaneous Intracerebral Hemorrhage: No Recommendation

• For non-traumatic ICH, tranexamic acid reduces hematoma expansion but does not improve functional outcomes or reduce mortality. 2, 6, 7
• The European Society of Intensive Care Medicine makes no recommendation for or against TXA in this population due to insufficient evidence of clinical benefit. 2
• While TXA reduces hematoma expansion (OR 0.87,95% CI 0.77-0.99) and hemorrhagic volume change, this does not translate to better 90-day functional outcomes or reduced mortality (RR 1.02,95% CI 0.88-1.19). 6, 7

If Considering TXA in ICH Despite Lack of Recommendation:

• Administer within 4.5 hours of symptom onset using standard dosing (1g IV over 10 minutes, then 1g over 8 hours). 3, 7
• Consider only in high-risk populations with CT markers of hematoma expansion (spot sign, irregular hematoma shape). 7
• The benefit is limited to reducing radiographic hematoma expansion without improving clinical outcomes. 7, 8
• TXA does not reduce the need for neurosurgical intervention. 9

Aneurysmal Subarachnoid Hemorrhage: No Recommendation

• The European Society of Intensive Care Medicine makes no recommendation regarding TXA in aneurysmal SAH. 2
• While TXA reduces rebleeding risk (RR 0.6,95% CI 0.44-0.8), this benefit is offset by increased stroke risk (RR 1.29,95% CI 1.01-1.67). 2
• No impact on mortality (RR 1.01,95% CI 0.88-1.16) or poor functional outcome has been demonstrated. 2
• The decision to use TXA must weigh individual risk of rebleeding versus stroke, and time until definitive aneurysm securement. 2

Safety Profile Across All Brain Bleeds

• Tranexamic acid does not significantly increase thromboembolic complications (stroke, MI, venous thromboembolism) in brain hemorrhage populations. 2, 6, 7
• Higher doses above 100 mg/kg increase seizure risk, particularly in cardiac surgery and TBI patients. 4, 5
• Infuse no faster than 1 mL/minute to avoid hypotension. 1

Critical Pitfalls to Avoid

• Never use TXA in subarachnoid hemorrhage—this is an absolute FDA contraindication. 1
• Do not delay administration beyond 3 hours in traumatic brain injury, as effectiveness decreases by 10% for every 15-minute delay. 4, 5
• Do not expect improved functional outcomes or reduced mortality in spontaneous ICH despite reduction in hematoma expansion. 2, 6
• Avoid confusing the radiographic benefit (less hematoma expansion) with clinical benefit (better outcomes)—these have not correlated in brain bleeds. 10, 6