Can tranexamic acid be used in acute intracranial hemorrhage if given early to patients with GCS ≥ 13 and low thrombotic risk?

Tranexamic Acid in Acute Intracranial Hemorrhage

Yes, tranexamic acid can be used in acute intracranial hemorrhage (brain bleeds) when administered early (within 3 hours) to patients with mild-to-moderate injury (GCS ≥ 13), but it does not improve functional outcomes or mortality despite reducing hematoma expansion. 1, 2

Evidence-Based Dosing Protocol

Administer 1 g IV loading dose over 10 minutes, followed by 1 g IV infusion over 8 hours. 3, 4 This regimen is derived from the CRASH-2 trauma trial and was adopted for intracerebral hemorrhage in the TICH-2 study. 3

Critical Timing Requirements

• Administer within 3 hours of symptom onset - effectiveness decreases by 10% for every 15-minute delay. 3, 4
• Optimal benefit occurs within 1 hour of injury, particularly in patients with shock index < 0.9. 1
• Do NOT administer after 3 hours - late administration may paradoxically increase risk of death due to bleeding and thromboembolic events. 3, 4, 5

Patient Selection Criteria

Appropriate candidates:

• Mild-to-moderate traumatic brain injury (GCS ≥ 13) treated within 3 hours shows reduced head injury-related death (risk ratio 0.78). 1
• Spontaneous intracerebral hemorrhage presenting within 8 hours. 3
• Patients with both pupils reactive to light. 1

Avoid in:

• Severe head injury (GCS < 8) - no mortality benefit demonstrated and potential for harm. 1, 6
• Patients with renal dysfunction require dose reduction as TXA is renally excreted. 3
• Absolute contraindication: subarachnoid hemorrhage - risk of cerebral edema and infarction. 3

Clinical Outcomes: The Reality Check

While TXA reduces hematoma expansion (odds ratio 0.79) and hemorrhagic lesion growth by approximately 2 mL 7, this radiographic benefit does not translate to improved functional outcomes, reduced mortality, or decreased need for neurosurgery. 6, 7 The CRASH-3 trial (n=12,737) showed only marginal mortality reduction in the overall population (18.5% vs 19.8%, not statistically significant). 1

Safety Profile and Thromboembolic Risk

• Overall thromboembolic risk is not significantly increased with standard dosing (relative risk 1.11, not significant). 5
• However, prolonged administration beyond 1 day increases thromboembolic events (relative risk 1.22). 5
• Delayed administration beyond 8 hours also increases thromboembolic risk (relative risk 1.16). 5
• Do not exceed 100 mg/kg total dose to minimize seizure risk, particularly in patients over 50 years. 3, 4

Common Pitfalls to Avoid

• Waiting for viscoelastic testing results - guidelines explicitly recommend NOT delaying TXA for thromboelastography results. 1
• Using in severe TBI (GCS < 8) - no benefit demonstrated and recent out-of-hospital data suggest potential harm. 1, 6
• Administering after the 3-hour window - this is associated with worse outcomes. 1, 3, 4
• Confusing with subarachnoid hemorrhage - TXA may prevent rebleeding in aneurysmal SAH but increases delayed cerebral ischemia and does not improve outcomes; it remains contraindicated. 3, 2

Route of Administration

Intravenous administration is the only FDA-approved and evidence-based route. 3, 4 Intraosseous access produces similar drug exposure and may be used when IV access is difficult in prehospital settings. 8