Effect of Tranexamic acid for acute spontaneous intracerebral haemorrhage: A systematic review and individual patient data meta-analysis

BackgroundSpontaneous intracerebral haemorrhage (ICH) has high rates of death and disability, and no proven haemostatic treatment. Tranexamic acid might limit haematoma expansion and improve outcomes. We conducted the first individual patient data meta-analysis to evaluate the effect of tranexamic acid on functional outcomes in spontaneous ICH. MethodsThis systematic review and individual patient data meta-analysis included randomised controlled trials comparing intravenous tranexamic acid to placebo in adults with spontaneous ICH treated within 12 hours of onset. MEDLINE, EMBASE, CENTRAL, Web of Science, and WHO ICTRP were searched to November 2024. The primary outcome was functional status at 90 days after randomisation, measured by the modified Rankin Scale. Adverse events (seizures, thromboembolic events) were also summarised. Analyses used generalised linear mixed models with random intercepts for trial. Risk of bias was assessed using the Cochrane RoB 2 tool. The study was registered with PROSPERO (CRD42022345775). ResultsWe identified 1,131 records; nine trials (3,194 participants) were eligible for inclusion and five trials (2860 participants; 90% of those available) provided individual patient data for the primary analysis. Risk of bias was low across all included trials. At 90 days, 757/1423 (53.2%) patients assigned to tranexamic acid had a worse functional outcome compared with 759/1415 (53.6%) assigned to placebo, the difference was not statistically significant (adjusted common odds ratio 0.93 (95% CI 0.81 to 1.07; p = 0.30). Serious adverse events were similar between the groups, with no significant differences observed. There was no evidence of between-trial heterogeneity based on model fit (likelihood ratio test). DiscussionCompleted clinical trials provide no evidence that tranexamic acid improves functional outcome after spontaneous ICH. However, given the reduction in hematoma expansion and early mortality it remains to be seen if this translates to improved functional outcome in larger ongoing clinical trials. Even a small beneficial effect could have potential for global impact given the burden of ICH. FundingNo funding source.