Zhe Kang Law1,2, Atte Meretoja3,4, Stefan T Engelter5,6,7, Hanne Christensen8, Eugenia-Maria Muresan9,10, Solveig B Glad11, Liping Liu12, Philip M Bath1, Nikola Sprigg1. 1. Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK. 2. Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia. 3. Department of Neurology, Helsinki University Hospital, Helsinki, Finland. 4. Department of Medicine at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. 5. Stroke Center and Neurology, University Hospital Basel, Basel, Switzerland. 6. Neurorehabilitation Unit, University of Basel, Basel, Switzerland. 7. University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland. 8. Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark. 9. Emergency Clinical County Hospital Cluj-Napoca, Cluj-Napoca, Romania. 10. Department of Emergency Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania. 11. Department of Neurology, Haukeland University Hospital, Bergen, Norway. 12. Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.
Abstract
PURPOSE: Haematoma expansion is a devastating complication of intracerebral haemorrhage (ICH) with no established treatment. Tranexamic acid had been an effective haemostatic agent in reducing post-operative and traumatic bleeding. We review current evidence examining the efficacy of tranexamic acid in improving clinical outcome after ICH. METHOD: We searched MEDLINE, EMBASE, CENTRAL and clinical trial registers for studies using search strategies incorporating the terms 'intracerebral haemorrhage', 'tranexamic acid' and 'antifibrinolytic'. Authors of ongoing clinical trials were contacted for further details. FINDINGS: We screened 268 publications and retrieved 17 articles after screening. Unpublished information from three ongoing clinical trials was obtained. We found five completed studies. Of these, two randomised controlled trials (RCTs) comparing intravenous tranexamic acid to placebo (n = 54) reported no significant difference in death or dependency. Three observational studies (n = 281) suggested less haematoma growth with rapid tranexamic acid infusion. There are six ongoing RCTs (n = 3089) with different clinical exclusions, imaging selection criteria (spot sign and haematoma volume), time window for recruitment and dosing of tranexamic acid. DISCUSSION: Despite their heterogeneity, the ongoing trials will provide key evidence on the effects of tranexamic acid on ICH. There are uncertainties of whether patients with negative spot sign, large haematoma, intraventricular haemorrhage, or poor Glasgow Coma Scale should be recruited. The time window for optimal effect of haemostatic therapy in ICH is yet to be established. CONCLUSION: Tranexamic acid is a promising haemostatic agent for ICH. We await the results of the trials before definite conclusions can be drawn.
PURPOSE: Haematoma expansion is a devastating complication of intracerebral haemorrhage (ICH) with no established treatment. Tranexamic acid had been an effective haemostatic agent in reducing post-operative and traumatic bleeding. We review current evidence examining the efficacy of tranexamic acid in improving clinical outcome after ICH. METHOD: We searched MEDLINE, EMBASE, CENTRAL and clinical trial registers for studies using search strategies incorporating the terms 'intracerebral haemorrhage', 'tranexamic acid' and 'antifibrinolytic'. Authors of ongoing clinical trials were contacted for further details. FINDINGS: We screened 268 publications and retrieved 17 articles after screening. Unpublished information from three ongoing clinical trials was obtained. We found five completed studies. Of these, two randomised controlled trials (RCTs) comparing intravenous tranexamic acid to placebo (n = 54) reported no significant difference in death or dependency. Three observational studies (n = 281) suggested less haematoma growth with rapid tranexamic acid infusion. There are six ongoing RCTs (n = 3089) with different clinical exclusions, imaging selection criteria (spot sign and haematoma volume), time window for recruitment and dosing of tranexamic acid. DISCUSSION: Despite their heterogeneity, the ongoing trials will provide key evidence on the effects of tranexamic acid on ICH. There are uncertainties of whether patients with negative spot sign, large haematoma, intraventricular haemorrhage, or poor Glasgow Coma Scale should be recruited. The time window for optimal effect of haemostatic therapy in ICH is yet to be established. CONCLUSION: Tranexamic acid is a promising haemostatic agent for ICH. We await the results of the trials before definite conclusions can be drawn.
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