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Tranexamic Acid Within 4.5 Hours of Intracerebral Hemorrhage With the CTA Spot Sign: Systematic Review and Individual
Nawaf Yassi1, Vignan Yogendrakumar1, Leonid Churilov1
1From the Department of Medicine and Neurology (N.Y., V.Y., L.C., B.C.V.C., H.Z., G.A.D., S.M.D.), Melbourne Brain Centre @ The Royal Melbourne Hospital, University of Melbourne; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia; Division of Neurology (V.Y.), Department of Medicine, The Ottawa Hospital and Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Melbourne Medical School (L.C.), University of Melbourne, Parkville, Australia; Department of Neurology (A.M., D.S.), Helsinki University Hospital, Finland; Department of Neurology (T.W.), Christchurch Hospital, New Zealand; Stroke Centre and Department of Neurology (J.-S.J.), National Taiwan University Hospital, Taipei; Stroke Trials Unit (L.J.W., Z.K.L., P.M.B., N.S.), Mental Health & Clinical Neuroscience, University of Nottingham, United Kingdom; Department of Neurology (C.O.), Bispebjerg and Frederiksberg Hospital, University Hospital of Copenhagen, Denmark; Department of Medicine (Z.K.L.), Faculty of Medicine, National University of Malaysia, Kuala Lumpur; Department of Neurology (H.-Q.G., X.N., J.L., L.L.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Centre for Neurological Diseases (H.-Q.G., X.N., J.L., L.L.), Beijing; and Department of Neurology (H.H.M.), Monash Medical Centre, School of Clinical Sciences, Monash University, Melbourne, Australia.
Background And Objectives:
The antifibrinolytic agent tranexamic acid has been tested in intracerebral hemorrhage trials with overall neutral results. Ongoing contrast extravasation on CT angiography (spot sign) can identify individuals with ongoing bleeding who may benefit from anti-fibrinolytic therapy. We aimed to investigate the effect of tranexamic acid on hematoma growth in patients with spot signs treated within 4.5 hours of onset.
Methods:
We conducted a systematic review and individual patient meta-analysis, which we report according to the Preferred Reporting Items for Systematic Review and Meta-analyses of Individual Participant Data guidelines. PubMed and Embase were searched from inception to May 29, 2023, using the terms ((stroke) AND (randomised OR randomized) AND (tranexamic acid) AND (haemorrhage OR hemorrhage)). We included randomized trials comparing tranexamic acid with placebo in participants with primary intracerebral hemorrhage who had a spot sign and who had follow-up imaging within the required timeframe. Individual patient data were provided by each study and were integrated by the coordinating center. Data were pooled using a random-effects model. The primary endpoint was hematoma growth within 24 hours, defined as ≥33% relative or ≥6 mL absolute hematoma expansion compared with baseline, analyzed using mixed-effects-modified Poisson regression with robust standard errors, adjusted for baseline hematoma volume. Safety outcomes were mortality and major thromboembolic events within 90 days.
Results:
Of 197 studies identified, 3 were eligible, contributing 162 participants for the primary analysis (60 female and 102 male). Hematoma growth occurred in 36 of 74 (49%) participants treated with tranexamic acid, compared with 48 of 88 (55%) participants treated with placebo (adjusted risk ratio 0.86, 95% CI 0.84-0.89, p < 0.001). Adjusted median absolute hematoma growth was 1.60 mL (95% CI 0.77-2.43) lower with tranexamic acid vs placebo. No differences in functional outcome or safety were observed.
Discussion:
Tranexamic acid modestly reduced hematoma growth in patients with CT angiography spot signs treated within 4.5 hours of onset. Given the trials in the meta-analysis were individually neutral, these results require further validation before clinical application.
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