Stroke: After cerebral hemorrhage, tranexamic acid does not improve hematoma expansion

Intraparenchymal hematoma expansion (Intraparenchymal hematoma expansion) is regarded as the goal of therapeutic intervention to improve the outcome of patients with spontaneous intracerebral hemorrhage
.
Recent studies have shown that the risk of hematoma enlargement is greatest in the first few hours after the onset of symptoms and gradually decreases in the first 24 hours

In the TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage;), as well as previous trials in which participants with acute spontaneous intracerebral hemorrhage were randomly added to hemostatic agents and placebos, it has been proven that although hematoma expansion can be limited to a certain extent , But it has not yet proven the improvement of the functional outcome on the 90th day
.

Since previous trials could not prove that in participants with relatively extensive intracerebral hemorrhage, the use of hemostatic agents can improve functional outcomes.
Therefore, some people recommend that participants with a higher risk of hematoma enlargement use hemostatic agents selectively

The biomarker of hematoma enlargement is the spot sign on CT- angiography or contrast-enhanced CT
.
The speckle sign is considered to represent the blood rich in contrast agent, actively infiltrating the hematoma, and it has been found in some independent studies to be a powerful predictor of hematoma enlargement

Since patients with positive spot signs are considered to have persistent hematoma expansion, it is assumed that these patients will benefit from the use of hemostatic agents compared with patients with negative spot signs
.
To date, 3 smaller clinical trials have randomly assigned patients with positive punctiform signs to hemostatic agents and placebos

The TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) is a randomized, placebo-controlled clinical trial that recruits acute hospitalized participants who suffer from intracerebral hemorrhage within 8 hours of the onset of symptoms
.
The local investigator randomly assigned the participants to 2 grams of intravenous tranexamic acid or a matching placebo (1:1)

All participants underwent CT scans on admission and on the second day (24 ± 12 hours) after randomization
.
In this subgroup analysis, all participants in the main test population were included, and imaging examinations allowed for the judgment of the status of spot signs

They found that out of 2,325 TICH-2 participants, 254 (10.
9%) could judge the imaging of the speckle sign
.

Among these participants, 64 (25.
2%) were positive for the blob sign
.
The median (quartile) time from symptom onset to intervention was 225.

Compared with placebo, the percentage difference in the absolute volume of hematoma on the second day after adjustment for participants assigned to tranexamic acid was 3.
7% for those with positive punctate signals and 1.
7% for those with negative punctate signals
.

Among the participants with positive (OR=0.

The important significance of this study is the discovery: The data from the TICH-2 trial does not support the state of punctate signs at the time of admission, and will change the treatment effect of tranexamic acid and placebo in patients with acute intracerebral hemorrhage
.
Results may be affected by low statistical power and treatment delays
.

Original source:
Ovesen C, Jakobsen JC, Gluud C, et al.
Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign.
Stroke.
2021;52(8):2629-2636.
doi:10.
1161/STROKEAHA .
120.
032426