Impact of tranexamic acid on outcomes in early-admitted patients with aneurysmal subarachnoid hemorrhage: a systematic review and bayesian meta-analysis of randomized controlled trials.

Aneurysmal subarachnoid hemorrhage (aSAH) represents one of the acute neurological conditions associated with the highest morbidity and mortality, often complicated by early rebleeding in the hyperacute phase. Tranexamic acid (TXA), an antifibrinolytic agent, has been proposed to reduce the risk of rebleeding; however, its impact on outcomes in patients admitted early (≤ 72 h) remains unclear. The authors searched PubMed, Embase, Web of Science, and Cochrane for randomized controlled trials evaluating TXA use among aSAH patients admitted early to the hospital (≤ 72 h). The authors performed a traditional frequentist and Bayesian meta-analyses with informative priors for heterogeneity. Additionally, studies were stratified by whether they used a long-term or short-term TXA protocol. After a comprehensive search, 6 randomized trials were included in this review. Bayesian meta-analysis showed a significant reduction of rebleeding events (RR 0.59; 95% CrI 0.38 to 0.90) and rebleeding-related mortality (RR 0.55; 95% CrI 0.33 to 0.93) in the TXA cohort. Notably, the long-term TXA protocol subgroup showed a significant increase in cerebral ischemia events (RR 1.68; 95% CrI 1.13 to 2.51), while the short-term protocol did not yield a significant increase (96.3% probability of subgroup difference). There was no significant difference in overall-cause mortality (RR 1.01; 95% CrI 0.83 to 1.24), and poor neurological outcome at last follow-up (RR 1.02; 95% CrI 0.79 to 1.29). This study suggests that the use of TXA in early aSAH may reduce the incidence of rebleeding and rebleeding-related mortality. However, the impact of TXA does not directly translate into reduced all-cause mortality or enhanced neurological outcome. Long-term TXA protocols may increase potential ischemic complications and are not recommended.