Should tranexamic acid be administered to a patient with aneurysmal subarachnoid hemorrhage (aSAH) who will receive early aneurysm treatment, Computed Tomography (CT) Angiography confirmed, with a history of smoking, presenting with severe headache and impaired mental status, and a low Glasgow Coma Scale (GCS) score, indicating severe impaired consciousness?

From the Guidelines

The most appropriate recommendation for TJ is to not administer tranexamic acid because the ULTRA study failed to show improvement in outcomes at 6 months in patients receiving early tranexamic acid, and thus antifibrinolytic therapy is not recommended 1. Tranexamic acid is an antifibrinolytic agent that can reduce the risk of rebleeding in aneurysmal subarachnoid hemorrhage (aSAH) by inhibiting the breakdown of blood clots. However, the primary goal in managing aSAH is to secure the aneurysm as quickly as possible, which will be accomplished through the planned coil embolization. Some key points to consider in this case include:

• The ULTRA study provides convincing evidence that the use of tranexamic acid does not significantly decrease the rate of rebleeding and is not effective to improve functional outcomes in patients with aSAH whose ruptured aneurysm is obliterated early 1.
• The potential complications associated with tranexamic acid can worsen neurological outcomes in patients with aSAH.
• Proceeding directly to early aneurysm treatment without tranexamic acid administration is the preferred approach, as the benefit of preventing rebleeding with tranexamic acid is outweighed by the potential risks. The 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage also supports this approach, stating that antifibrinolytic therapy is not recommended based on the results of the ULTRA trial 1.

From the FDA Drug Label

Tranexamic acid Injection 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.

The most appropriate recommendation for tranexamic acid administration to this patient who will receive early aneurysm treatment is: Do not administer tranexamic acid because it is contraindicated in patients with subarachnoid hemorrhage 2.

From the Research

Tranexamic Acid Administration in Aneurysmal Subarachnoid Hemorrhage

• The use of tranexamic acid in patients with aneurysmal subarachnoid hemorrhage (aSAH) has been studied in several clinical trials 3, 4, 5, 6, 7.
• The primary benefit of tranexamic acid in aSAH is the reduction of rebleeding risk, as demonstrated in multiple studies 3, 4, 6, 7.
• However, the effect of tranexamic acid on mortality and clinical outcomes is less clear, with some studies suggesting no significant benefit 4, 5, 6, 7.
• There is evidence to suggest that tranexamic acid may increase the risk of hydrocephalus and seizure 6.
• The current evidence does not support the routine use of tranexamic acid in patients with aSAH, and its administration should be considered on a case-by-case basis 6, 7.

Considerations for Tranexamic Acid Administration

• The decision to administer tranexamic acid should be based on the individual patient's risk of rebleeding and the potential benefits and risks of treatment.
• Early aneurysm treatment (less than 24 hours after rupture) is recommended to minimize the risk of rebleeding and improve outcomes.
• The use of tranexamic acid should be considered in the context of the overall treatment plan, including the timing of aneurysm treatment and the patient's clinical condition.