Practice Uncertainties

Does tranexamic acid improve outcomes in traumatic brain injury?

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4814 (Published 28 September 2016) Cite this as: BMJ 2016;354:i4814

This article has a correction. Please see:

  1. Abda Mahmood, doctoral candidate in epidemiology and population health1,
  2. Ian Roberts, professor of epidemiology and population health1,
  3. Haleema Shakur, senior lecturer in clinical trials1,
  4. Tim Harris, professor of emergency medicine2,
  5. Antonio Belli, professor of trauma neurosurgery3
  1. 1Clinical Trials Unit, London School of Hygiene and Tropical Medicine, University of London, UK
  2. 2Department of Emergency Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK
  3. 3NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  1. Correspondence to: A Mahmood Abda.Mahmood{at}lshtm.ac.uk

What you need to know

  • The effectiveness and safety of tranexamic acid in traumatic brain injury is uncertain, although randomised trials are under way to investigate the problem

  • Tranexamic acid could reduce intracranial bleeding but might increase the risk of cerebral thrombosis and ischaemia

  • We believe that tranexamic acid should not be used in routine clinical practice unless these trials show benefit

Worldwide at least 200 per 100 000 people are killed or admitted to hospital each year after traumatic brain injury.1 This results in more than 10 million deaths or hospital admissions.2 In the UK, around one million people attend emergency departments every year with a traumatic brain injury.3

Intracranial bleeding is common after traumatic brain injury, and the larger the bleed the greater the risk of death and disability.4 5 Bleeding continues after hospital admission in 84% of patients with moderate or severe injuries,6 7 and can continue for up to 24 hours.8 About one third of patients have laboratory evidence of abnormal coagulation.9 High levels of fibrin degradation products are seen within the first three hours.10 Such patients have a higher risk of intracranial haemorrhage and mortality.

Tranexamic acid reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots (fig 1).

Fig 1 A Normal fibrinolysis. B: Fibrinolysis inhibited by tranexamic acid. Plasmin binds to fibrin via lysine binding sites and then splits fibrin into fibrin degradation products. Tranexamic acid is a molecular analogue of lysine that inhibits fibrinolysis by reducing the binding of plasmin to fibrin

Tranexamic acid is used routinely in some cases of trauma and in surgery. For example, it reduces the need for blood transfusion in surgical patients.11 12 In trauma patients with extracranial haemorrhage:13

  • Tranexamic acid treatment within an hour of injury reduces the risk …

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