A technical report of downstream cerebrospinal fluid lavage for tranexamic acid intrathecal toxicity

Iatrogenic tranexamic acid central nervous system toxicity resulting from intrathecal injection is a rare event with a high case fatality rate. This technical report documents the success of downstream cerebrospinal fluid lavage in a patient presenting in status epilepticus following inadvertent intrathecal tranexamic acid injection.

The combination of external ventricular drain and lumbar drain placement was utilized for near continuous cerebrospinal fluid lavage to treat intrathecal tranexamic toxicity. Warmed sterile preservative-free normal saline is irrigated in eight 10 mL aliquots over 20 min (total 80 mL/20 min) every hour for 22 h through the external ventricular drain, with simultaneous aspiration through the lumbar drain to maintain consistent cerebrospinal fluid volume and pressure. No elevations in intracranial pressure recordings were noted during the 22 h lavage period and resulted in seizure control and normalization of the patient's neurologic examination.

The implementation of downstream lavage through two points of cerebrospinal fluid access may lead to reduction in mortality rates of tranexamic acid and other central nervous system toxicities. Though demanding on neurosurgery team resources, continuous cerebral spinal fluid lavage had the potential to be a lifesaving technique.

This regimen can be considered for these rare but life-threatening cases of tranexamic acid neurotoxicity in which the risks of hemorrhage and infection is outweighed by the potential benefits of cerebrospinal fluid dilution.