Antifibrinolytics in the treatment of traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of trauma-related deaths, and pharmacologic interventions to limit intracranial bleeding should improve outcomes. Tranexamic acid reduces mortality in injured patients with major systemic bleeding, but the effects of antifibrinolytic drugs on outcomes after TBI are less clear. We therefore summarize recent evidence to guide clinicians on when (not) to use antifibrinolytic drugs in TBI patients.

Tranexamic acid is the only antifibrinolytic drug that has been studied in patients with TBI. Several recent studies failed to conclusively demonstrate a benefit on survival or neurologic outcome. A large trial with more than 12 000 patients found no significant effect of tranexamic acid on head-injury related death, all-cause mortality or disability across the overall study population, but observed benefit in patients with mild to moderate TBI. Observational evidence signals potential harm in patients with isolated severe TBI.

Given that the effect of tranexamic acid likely depends on a variety of factors, it is unlikely that a 'one size fits all' approach of administering antifibrinolytics to all patients will be helpful. Tranexamic acid should be strongly considered in patients with mild to moderate TBI and should be avoided in isolated severe TBI.