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. 2025 Jun 17:16:1617817.
doi: 10.3389/fneur.2025.1617817. eCollection 2025.

Efficacy and safety of tranexamic acid administration for subarachnoid hemorrhage: a systematic review and meta-analysis

Eriya Imai  1 , Hiroshi Ito  2 , Hiromu Okano  3 , Akihiko Inoue  4 , Takero Terayama  5 , Hiroshi Okamoto  3 , Toru Hifumi  6 , Yoshihisa Fujimoto  7 , Gaku Fujiwara  8 , Yasuhiro Kuroda  9
Affiliations

Efficacy and safety of tranexamic acid administration for subarachnoid hemorrhage: a systematic review and meta-analysis

Eriya Imai et al. Front Neurol. .

Abstract

Introduction: Aneurysmal subarachnoid hemorrhage (SAH) carries a high risk of early rebleeding and worsens prognosis. Tranexamic acid (TXA), an antifibrinolytic agent, can prevent rebleeding; however, its effects on mortality and neurological outcomes remain controversial.

Methods: This review evaluated the efficacy and safety of TXA with SAH. MEDLINE, CENTRAL, EMBASE, ICTRP, and ClinicalTrials.gov were systematically searched for randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) to assess TXA use in SAH. Studies comparing TXA with controls with SAH were included. The primary outcome was the mortality; secondary outcomes included neurological outcomes, rebleeding, thromboembolism, delayed cerebral ischemia (DCI), hydrocephalus, and adverse events. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

Results: Fifteen RCTs (3,109 patients) and nine NRSIs (1,506 patients) were included. RCTs demonstrated that TXA likely does not reduce mortality (risk ratio [RR], 1.00; 95% confidence interval [CI], 0.82-1.22; moderate certainty) and neurological outcome, and may not increase thromboembolism and DCI. However, TXA probably reduces rebleeding but probably increases hydrocephalus. The NRSIs results were similar.

Discussion: Although routine use is not supported, TXA may be considered for high-risk patients when early aneurysm treatment is unavailable.

Systematic review registration: https://osf.io/yp78b/.

Keywords: meta-analysis; rebleeding; subarachnoid hemorrhage; systematic review; tranexamic acid.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
PRISMA 2020 flow diagram. CENTRAL: Cochrane Central Register of Controlled Trials; ICTRP, International Clinical Trials Registry Platform; RCTs, Randomized Controlled Trials.
Figure 2
Figure 2
Risk of bias in the included studies evaluating the mortality. (a) Randomized controlled trials. (b) Non-randomized studies of interventions.
Figure 3
Figure 3
Forest plot of primary and secondary outcomes. (a) Mortality. (b) Good neurological outcomes. (c) Rebleeding. (d) Thromboembolism. (e) Delayed cerebral ischemia. (f) Hydrocephalus. CI, confidence interval; df, degrees of freedom; M–H, Mantel–Haenszel; SD, standard deviation; TXA, tranexamic acid.
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