June 7, 2021

An article review from the ESICM Journal Review Club

An update on literature about the use of TXA in TBI


The role of tranexamic acid (TXA) in patients with acute traumatic brain injury (TBI) or intracranial bleeding is still controversial. Considering the conflicting trial results in improving head injury-related deaths, Lawati et al. conducted a meta-analysis to determine the safety and efficacy of TXA in these patients.

The authors summarized nine RCT (14,747 patients), which resulted in a pooled relative risk (RR) (95% confidence interval [CI]) of TXA of 0.95 (0.88–1.02) for mortality.

The key findings are:
– TXA likely had no effect on mortality or disability assessed by the Disability Rating Scale.
– TXA may reduce hematoma expansion on subsequent imaging.
– There is probably no increased risk of adverse events, but no advantages were observed for using TXA in TBI patients.


– The most recent and extensive meta-analysis, including CRASH-3 and a comprehensive literature search with unpublished sources, duplicate and independent screening and data abstraction.
– GRADE assessment of certainty of evidence.
– The findings of this review could be of interest to future guidelines addressing the topic of TXA in TBI, balancing benefits, harms, values, preferences, and costs.

– Not enough data to settle the pre-planned subgroup analyses debated in the CRASH-3 RCT.
– The Authors tried to limit the analysis to studies that enrolled patients with isolated TBI. However, some of them included a small number of patients with TBI and extracranial injuries.


In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging. The use of TXA likely does not increase the risk of adverse events, but the benefit in terms of long-term outcome remains unclear.

This article review was prepared and submitted by Dr Serena Ranieri, Department of Anaesthesia, Intensive Care and Emergency Medical Services, Maggiore Hospital, Bologna, Italy, on behalf of the ESICM Journal Review Club.


Al Lawati K., et al. “Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials.” Intensive Care Medicine (2020): 1-14.

Comment on this news