Tranexamic acid in spontaneous intracerebral hemorrhage: a meta-analysis

Spontaneous intracerebral hemorrhage (sICH) is a critical and disabling form of stroke and accounts for an obvious number of stroke-related deaths and disabilities globally. Hematoma growth is a key target for therapeutic intervention because of its association with poor outcomes. Recently, the STOP-MSU trial showed that intravenous tranexamic acid (TA) did not reduce hematoma growth or improve clinical outcomes when administered within 2 h of intracerebral hemorrhage symptom onset. This study aims to evaluate the efficacy of TA in reducing hematoma growth and improving clinical outcomes in patients with spontaneous sICH by incorporating the findings from the latest STOP-MSU trial and consolidating past research to clarify the overall efficacy and safety of TA on sICH.

A systematic review and meta-analysis were conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA guidelines. We included randomized controlled trials (RCTs) comparing TA to placebo in adult patients with sICH. Databases such as PubMed, Medline, and Cochrane were searched up to May 2024. Key outcomes analyzed included hematoma expansion, mortality within 90 days, thromboembolic events, and favorable functional outcomes. Data were pooled using a random-effects model and analyzed using the "metafor" package in RStudio.

Five RCTs involving 1419 patients were included. The meta-analysis showed no significant difference in hematoma expansion (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.74-1.03), mortality within 90 days (OR 1.03, 95% CI 0.86-1.24), thromboembolic events (OR 1.07, 95% CI 0.69-1.64), and favorable functional outcomes (modified Rankin Scale of 0-2 at 90 days; OR 1.04, 95% CI 0.88-1.22) between the TA and placebo groups.

TA does not significantly reduce hematoma growth or improve clinical outcomes in patients with sICH. Despite its affordability and availability, the routine use of TA in sICH is not supported by current evidence.