• Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury

    • Dec 01, 2020
    •  Katherine Wagner, MD and Jamie Sue Ullman, MD, Manhasset, NY

    • Cerebrovascular

    • Background: Fibrinolysis peaks 3 hours after traumatic brain injury (TBI). Tranexamic acid (TXA), an anti-fibrinolytic agent, may mitigate this and prevent subsequent hematoma expansion. 
    • Randomized, multicenter clinical trial enrolling 966 patients at 20 trauma centers in the US and Canada, from May 2015 - November 2017.
    • Patients were randomized to three groups:
      • Out-of-hospital TXA bolus (1 gram) and in-hospital bolus (1 gram) over 8 hours (bolus maintenance group, n=312)
      • Out-of-hospital TXA bolus (2 grams) and in-hospital placebo infusion over 8 hours (bolus only group, n=345)
      • Out of hospital placebo bolus and in-hospital placebo bolus (placebo group, n=309)
    • Treatment started within two hours of injury
    • The two-gram bolus dosing was trialed to evaluate its potential usefulness in prehospital and military settings, while the one-gram bolus dosing was based on the CRASH-2 trial.
    • Primary outcome was favorable neurologic function at 6 months (Glascow Outcome Scale- Extended > 4, corresponding to either moderate disability or good recovery).
    • Ultimately, the two TXA groups were combined and compared to the placebo group to ensure adequate power.
    • 1063 patients randomized, 966 participated (96 did not receive the study drug, one was excluded later).
    • Mean age 43 years old, 74% male, mean Glascow Coma Scale 8
    • The all-cause 28-day mortality was 14% in the combined TXA groups and 17% in the placebo group; this result was not statistically significant (p=0.26).
      • This result differs from what the CRASH-3 authors found for patients with mild to moderate TBI (see link in Sources).
    • The difference in the primary outcome of favorable neurologic outcome between the TXA groups and placebo group was -3.5%, (65% vs 62%, p=0.16 for benefit). This result was not statistically significant.  
    • There were more thrombotic events in the bolus only and placebo groups (9% and 10%, respectively) than in the bolus maintenance group (4%).
    • Bolus only patients were also more likely to experience seizures (5% versus 2% in the other two groups), but they received fewer blood transfusions than patients in the other groups. 

    Source

    JAMA

    doi: 10.1001/jama.2020.8958

    The Lancet (CRASH-3)

    doi.org/10.1016/S0140-6736(19)32312-8

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