Sigmon Jana, Crowley Kelli L, Groth Christine M
Harris Health System, Houston, TX, USA.
Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
Am J Health Syst Pharm. 2023 Sep 7;80(18):1213-1222. doi: 10.1093/ajhp/zxad134.
To summarize current literature evaluating tranexamic acid in the management of intracranial bleeding associated with traumatic and nontraumatic brain injuries and implications for clinical practice.
Intracranial hemorrhage, regardless of etiology, is associated with high morbidity and mortality. Tranexamic acid is an antifibrinolytic with anti-inflammatory properties shown to reduce mortality in trauma patients with extracranial injuries. In traumatic brain injury, a large randomized trial found no difference in outcomes when tranexamic acid was compared to placebo; however, subgroup analyses suggested that it may reduce head injury-related mortality in the context of mild-to-moderate injury if treatment occurs within 1 hour of symptom onset. More recent out-of-hospital data have disputed these findings and even suggested harm in severely injured patients. In spontaneous, nontraumatic intracranial hemorrhage, treatment with tranexamic acid did not result in a difference in functional status; however, rates of hematoma expansion, even though modest, were significantly reduced. In aneurysmal subarachnoid hemorrhage, tranexamic acid may prevent rebleeding, but has not led to improved outcomes or reduced mortality, and there is concern for increased incidence of delayed cerebral ischemia. Overall, tranexamic acid has not been shown to result in increased risk of thromboembolic complications across these classes of brain injury.
Despite its favorable safety profile overall, tranexamic acid does not seem to improve functional outcomes and cannot be routinely recommended. More data are needed to determine which head injury subpopulations are most likely to benefit from tranexamic acid and which patients are at increased risk for harm.
总结当前评估氨甲环酸在治疗与创伤性和非创伤性脑损伤相关的颅内出血中的应用的文献，以及对临床实践的启示。
颅内出血，无论病因如何，都与高发病率和死亡率相关。氨甲环酸是一种具有抗炎特性的抗纤维蛋白溶解剂，已显示可降低伴有颅外损伤的创伤患者的死亡率。在创伤性脑损伤中，一项大型随机试验发现，将氨甲环酸与安慰剂相比，结果没有差异；然而，亚组分析表明，如果在症状出现后1小时内进行治疗，它可能会降低轻度至中度损伤情况下与头部损伤相关的死亡率。最近的院外数据对这些发现提出了质疑，甚至表明对重伤患者有危害。在自发性非创伤性颅内出血中，使用氨甲环酸治疗并未导致功能状态出现差异；然而，血肿扩大率尽管较小，但显著降低。在动脉瘤性蛛网膜下腔出血中，氨甲环酸可能预防再出血，但并未带来更好的结局或降低死亡率，并且人们担心延迟性脑缺血的发生率会增加。总体而言，在这些类型的脑损伤中，尚未显示氨甲环酸会增加血栓栓塞并发症的风险。
尽管氨甲环酸总体安全性良好，但它似乎并未改善功能结局，因此不能常规推荐使用。需要更多数据来确定哪些头部损伤亚群最有可能从氨甲环酸中获益，以及哪些患者有更高的受伤害风险。
