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Baucom MR, Wallen TE, Price AD, England LG, Schuster RM, Goodman MD. Tranexamic Acid Administration Does Not Alter Inflammation After Traumatic Brain Injury, Regardless of Timing. J Surg Res 2024; 302:106-115. [PMID: 39094257 DOI: 10.1016/j.jss.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 05/15/2024] [Accepted: 07/04/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) administered early after traumatic brain injury (TBI) can decrease morbidity and mortality. The purpose of this study is to determine if the timing of TXA administration after TBI affects postinjury inflammatory markers or phosphorylated tau (p-tau) levels within the hippocampus. METHODS Male mice (9-11 wk) were split into six groups based on injury and timing of TXA administration (n = 5 per group): Sham, TBI-only, 100 mg/kg TXA-only, TBI + TXA 10 min, TBI + TXA 1 h, and TBI + TXA 6 h. Moderate concussive TBI was induced via weight drop. Serum and brain homogenates were collected at 6 and 24 h postinjury and analyzed for 14 inflammatory cytokines via multiplex enzyme-linked immunosorbent assay. Serum was analyzed for glial fibrillary acidic protein levels. Additional cohorts were survived to 30 d for hippocampal p-tau quantification using immunohistochemistry. RESULTS Serum levels of interleukin (IL) 1β (IL-1β), IL-3, IL-12, IL-17, monocyte chemoattractant protein-1, granulocyte-macrophage colony-stimulating factor, and regulated on activation, normal T-cell expressed and secreted were elevated in TBI mice compared to sham mice at 24 h. Levels of IL-1β and monocyte chemoattractant protein-1 were lower in 6-h TXA-treated mice than 1-h TXA-treated mice following TBI. IL-12 and macrophage inflammatory protein-1α levels were decreased in 6-h TXA-treated mice compared to 10-min TXA-treated mice. Administration of TXA at 10 min and 6 h but not 1 h postTBI reduced serum glial fibrillary acidic protein levels compared to TBI-only mice. Hippocampal p-tau accumulation was increased after TBI but not reduced by TXA administration. CONCLUSIONS Our results demonstrate that neither early nor delayed administration of TXA conveyed significant systemic or cerebral benefit in cytokine levels following TBI. Further research should be conducted to assess blood brain barrier integrity and neurobehavioral recovery following TXA administration postTBI.
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Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Taylor E Wallen
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Lisa G England
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Deshpande DV, McKinley WI, Benjamin AJ, Schreiber MA, Rowell SE. The Association Between Tranexamic Acid and Seizures in Moderate or Severe Traumatic Brain Injury. J Surg Res 2024; 301:359-364. [PMID: 39024715 DOI: 10.1016/j.jss.2024.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 05/28/2024] [Accepted: 06/23/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) administered within 2 h of injury reduces mortality in traumatic brain injury (TBI) with intracranial hemorrhage. TXA also reduces the seizure threshold in a dose-dependent manner. We examined whether a 2-g bolus of prehospital TXA administered in moderate or severe TBI is associated with seizure activity within 72 h of injury. METHODS Patients from the prehospital TXA for TBI trial with Glasgow Coma Scale < 13, blunt head injury, and time-of-seizure data were included in this analysis. The original trial randomized patients with suspected TBI to placebo, 1-g TXA bolus + 1-g 8-h TXA infusion, or 2-g TXA bolus within 2 h of injury. In this secondary analysis, multivariable logistic regression was performed to examine the association of treatment group with seizure incidence. The model controlled for age, Glasgow Coma Scale, Injury Severity Score, intracranial hemorrhage, Abbreviated Injury Scale-head, and home antiseizure medication use. RESULTS Of the 786 patients who met the inclusion criteria, 19 had seizures within 72 h (five in placebo, two in 1-g bolus/1-g infusion, and 12 in 2-g bolus). The 2-g TXA bolus was not associated with increased seizures compared to placebo (odds ratio 0.41, 95% confidence interval 0.12-1.18, P = 0.12). Home antiseizure medication use was associated with increased seizures (odds ratio 15.95, 95% confidence interval 3.79-60.57, P < 0.001). CONCLUSIONS A prehospital 2-g TXA bolus in moderate or severe TBI was not associated with increased seizure activity during the first 72 h after injury; however, limited power, limited use of continuous electroencephalography, and unavailable seizure prophylaxis data highlight the need for further study.
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Affiliation(s)
- David V Deshpande
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois.
| | - W Ian McKinley
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Andrew J Benjamin
- Surgery, Trauma and Acute Care Surgery, University of Chicago, Chicago, Illinois
| | - Martin A Schreiber
- Donald D. Trunkey Center for Civilian and Combat Casualty Care, Oregon Health & Science University, Portland, Oregon
| | - Susan E Rowell
- Surgery, Trauma and Acute Care Surgery, University of Chicago, Chicago, Illinois
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Chen LY, Wang JQ, Zhao YM, Feng YZ. Construction and validation of a nomogram for blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures in the elderly: a cross-sectional study. BMC Musculoskelet Disord 2024; 25:530. [PMID: 38987728 PMCID: PMC11238366 DOI: 10.1186/s12891-024-07661-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 07/04/2024] [Indexed: 07/12/2024] Open
Abstract
PURPOSE Few studies have focused on the risk factors leading to postoperative blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures (PHFs) in the elderly. Therefore, we designed this study to explore potential risk factors of blood transfusion after ORIF for PHFs. We have also established a nomogram model to integrate and quantify our research results and give feedback. METHODS In this study, we retrospectively analyzed the clinical data of elderly PHF patients undergoing ORIF from January 2020 to December 2021. We have established a multivariate regression model and nomograph. The prediction performance and consistency of the model were evaluated by the consistency coefficient and calibration curve, respectively. RESULTS 162 patients met our inclusion criteria and were included in the final study. The following factors are related to the increased risk of transfusion after ORIF: time to surgery, fibrinogen levels, intraoperative blood loss, and surgical duration. CONCLUSIONS Our patient-specific transfusion risk calculator uses a robust multivariable model to predict transfusion risk.The resulting nomogram can be used as a screening tool to identify patients with high transfusion risk and provide necessary interventions for these patients (such as preoperative red blood cell mobilization, intraoperative autologous blood transfusion, etc.).
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Affiliation(s)
- Lu-Ying Chen
- Department of Medical Ultrasonics, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village Ouhai District, Wenzhou, 325000, Zhejiang, China
| | - Ji-Qi Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying, Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, 325000, Zhejiang, China
| | - You-Ming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying, Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, 325000, Zhejiang, China
| | - Yong-Zeng Feng
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying, Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, 325000, Zhejiang, China.
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Zhang M, Liu T. Efficacy and safety of tranexamic acid in acute traumatic brain injury: A meta-analysis of randomized controlled trials. Am J Emerg Med 2024; 80:35-43. [PMID: 38502985 DOI: 10.1016/j.ajem.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/10/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate. METHODS PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety. RESULTS Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I2: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I2: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I2: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I2: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I2: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I2: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I2: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I2: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I2: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I2: 0%, p = 0.94). CONCLUSIONS TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.
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Affiliation(s)
- Minzhi Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central NervousSystem, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China.
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Dean T, Mendiola AS, Yan Z, Meza-Acevedo R, Cabriga B, Akassoglou K, Ryu JK. Fibrin promotes oxidative stress and neuronal loss in traumatic brain injury via innate immune activation. J Neuroinflammation 2024; 21:94. [PMID: 38622640 PMCID: PMC11017541 DOI: 10.1186/s12974-024-03092-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/05/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) causes significant blood-brain barrier (BBB) breakdown, resulting in the extravasation of blood proteins into the brain. The impact of blood proteins, especially fibrinogen, on inflammation and neurodegeneration post-TBI is not fully understood, highlighting a critical gap in our comprehension of TBI pathology and its connection to innate immune activation. METHODS We combined vascular casting with 3D imaging of solvent-cleared organs (uDISCO) to study the spatial distribution of the blood coagulation protein fibrinogen in large, intact brain volumes and assessed the temporal regulation of the fibrin(ogen) deposition by immunohistochemistry in a murine model of TBI. Fibrin(ogen) deposition and innate immune cell markers were co-localized by immunohistochemistry in mouse and human brains after TBI. We assessed the role of fibrinogen in TBI using unbiased transcriptomics, flow cytometry and immunohistochemistry for innate immune and neuronal markers in Fggγ390-396A knock-in mice, which express a mutant fibrinogen that retains normal clotting function, but lacks the γ390-396 binding motif to CD11b/CD18 integrin receptor. RESULTS We show that cerebral fibrinogen deposits were associated with activated innate immune cells in both human and murine TBI. Genetic elimination of fibrin-CD11b interaction reduced peripheral monocyte recruitment and the activation of inflammatory and reactive oxygen species (ROS) gene pathways in microglia and macrophages after TBI. Blockade of the fibrin-CD11b interaction was also protective from oxidative stress damage and cortical loss after TBI. CONCLUSIONS These data suggest that fibrinogen is a regulator of innate immune activation and neurodegeneration in TBI. Abrogating post-injury neuroinflammation by selective blockade of fibrin's inflammatory functions may have implications for long-term neurologic recovery following brain trauma.
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Affiliation(s)
- Terry Dean
- Gladstone Institute for Neurological Disease, San Francisco, CA, USA
- Center for Neurovascular Brain Immunology at Gladstone, University of California San Francisco, San Francisco, CA, USA
- Center for Neuroscience Research, Children's National Hospital, Washington, DC, USA
| | - Andrew S Mendiola
- Gladstone Institute for Neurological Disease, San Francisco, CA, USA
- Center for Neurovascular Brain Immunology at Gladstone, University of California San Francisco, San Francisco, CA, USA
- Department of Pharmacology, University of California San Diego, La Jolla, CA, USA
| | - Zhaoqi Yan
- Gladstone Institute for Neurological Disease, San Francisco, CA, USA
- Center for Neurovascular Brain Immunology at Gladstone, University of California San Francisco, San Francisco, CA, USA
| | - Rosa Meza-Acevedo
- Gladstone Institute for Neurological Disease, San Francisco, CA, USA
- Center for Neurovascular Brain Immunology at Gladstone, University of California San Francisco, San Francisco, CA, USA
| | - Belinda Cabriga
- Gladstone Institute for Neurological Disease, San Francisco, CA, USA
- Center for Neurovascular Brain Immunology at Gladstone, University of California San Francisco, San Francisco, CA, USA
| | - Katerina Akassoglou
- Gladstone Institute for Neurological Disease, San Francisco, CA, USA
- Center for Neurovascular Brain Immunology at Gladstone, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Jae Kyu Ryu
- Gladstone Institute for Neurological Disease, San Francisco, CA, USA.
- Center for Neurovascular Brain Immunology at Gladstone, University of California San Francisco, San Francisco, CA, USA.
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.
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McQuilten ZK, Wood EM, Medcalf RL. When to use tranexamic acid for the treatment of major bleeding? J Thromb Haemost 2024; 22:581-593. [PMID: 37827378 DOI: 10.1016/j.jtha.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent originally developed for the management of bleeding in the setting of postpartum hemorrhage (PPH). Over the last 15 years, there has been accumulating evidence on the use of TXA for the treatment of active bleeding in a variety of clinical contexts. Clinical trials have shown that the efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose. Early administration is important for efficacy, particularly in trauma and PPH. Further studies are needed to understand the mechanisms by which TXA provides benefit, optimal modes of administration and dosing, and its effect in some clinical settings, such as spontaneous intracerebral hemorrhage. There is no evidence that TXA increases the risk of thrombotic events in patients with major bleeding overall. However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding. There is also evidence of increased risk of seizures with the use of higher doses. This review summarizes the current evidence for the use of TXA for patients with active bleeding and highlights the importance of generating evidence of efficacy and safety of hemostatic interventions specific to the bleeding contexts-as findings from 1 clinical setting may not be generalizable to other contexts-and that of individual patient assessment for bleeding, thrombotic, and other risks, as well as important logistical and other practical considerations, to optimize care and outcomes in these settings.
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Affiliation(s)
- Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia.
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Poston JN, Brown SP, Ilich A, Ginsburg AS, Herren H, El Kassar N, Jensen CE, Triulzi DJ, Key NS, May S, Gernsheimer TB. Fewer severe infections with tranexamic acid in patients with hematologic malignancies. Res Pract Thromb Haemost 2024; 8:102358. [PMID: 38666065 PMCID: PMC11043644 DOI: 10.1016/j.rpth.2024.102358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/22/2024] [Accepted: 02/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding in a multitude of clinical settings from postpartum hemorrhage to trauma. TXA may have clinical effects unrelated to bleeding; plasminogen, the target of TXA, alters immune responses, and TXA appears to decrease the risk of infection in patients undergoing cardiac surgery, as well as joint arthroplasty. Objectives To address whether TXA alters rates of infection and inflammatory outcomes in patients with hematologic malignancies. Methods We performed a post hoc analysis of outcomes of patients randomized to receive either TXA or placebo in the double-blinded, multicenter American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (Clinicaltrials.gov identifier: NCT02578901). Results TXA did not change the overall rate of infections, but the rate of severe infections (Common Toxicology Criteria for Adverse Events grade 3+) was lower in patients who received TXA compared with the placebo group. Patients who experienced grade 3+ infections had higher rates of World Health Organization grade 2+ bleeding and red blood cell transfusion requirements than patients who did not experience a grade 3+ infection, irrespective of treatment group. TXA did not impact other inflammatory outcomes such as mucositis, rash, or graft vs host disease. Conclusion Patients with hematologic malignancies who received TXA had less severe infections than those who received placebo with no difference in overall rate of infection or other inflammatory outcomes. Further investigation is needed on the impact of TXA on infections in this population.
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Affiliation(s)
- Jacqueline N. Poston
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Hematology/Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Anton Ilich
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Sarah Ginsburg
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Christopher E. Jensen
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Darrell J. Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nigel S. Key
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Terry B. Gernsheimer
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Wang Z, Chen G. Immune regulation in neurovascular units after traumatic brain injury. Neurobiol Dis 2023; 179:106060. [PMID: 36871640 DOI: 10.1016/j.nbd.2023.106060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/19/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Survivors may experience movement disorders, memory loss, and cognitive deficits. However, there is a lack of understanding of the pathophysiology of TBI-mediated neuroinflammation and neurodegeneration. The immune regulation process of TBI involves changes in the peripheral and central nervous system (CNS) immunity, and intracranial blood vessels are essential communication centers. The neurovascular unit (NVU) is responsible for coupling blood flow with brain activity, and comprises endothelial cells, pericytes, astrocyte end-feet, and vast regulatory nerve terminals. A stable NVU is the basis for normal brain function. The concept of the NVU emphasizes that cell-cell interactions between different types of cells are essential for maintaining brain homeostasis. Previous studies have explored the effects of immune system changes after TBI. The NVU can help us further understand the immune regulation process. Herein, we enumerate the paradoxes of primary immune activation and chronic immunosuppression. We describe the changes in immune cells, cytokines/chemokines, and neuroinflammation after TBI. The post-immunomodulatory changes in NVU components are discussed, and research exploring immune changes in the NVU pattern is also described. Finally, we summarize immune regulation therapies and drugs after TBI. Therapies and drugs that focus on immune regulation have shown great potential for neuroprotection. These findings will help us further understand the pathological processes after TBI.
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Affiliation(s)
- Zongqi Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province 215006, China; Institute of Stroke Research, Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province 215006, China; Institute of Stroke Research, Soochow University, Suzhou, Jiangsu Province 215006, China.
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Effects of CNS Injury-Induced Immunosuppression on Pulmonary Immunity. Life (Basel) 2021; 11:life11060576. [PMID: 34207063 PMCID: PMC8235795 DOI: 10.3390/life11060576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 11/17/2022] Open
Abstract
Patients suffering from stroke, traumatic brain injury, or other forms of central nervous system (CNS) injury have an increased risk of nosocomial infections due to CNS injury-induced immunosuppression (CIDS). Immediately after CNS-injury, the response in the brain is pro-inflammatory; however, subsequently, local and systemic immunity is suppressed due to the compensatory release of immunomodulatory neurotransmitters. CIDS makes patients susceptible to contracting infections, among which pneumonia is very common and often lethal. Ventilator-acquired pneumonia has a mortality of 20–50% and poses a significant risk to vulnerable patients such as stroke survivors. The mechanisms involved in CIDS are not well understood. In this review, we consolidate the evidence for cellular processes underlying the pathogenesis of CIDS, the emerging treatments, and speculate further on the immune elements at play.
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Mutimer CA, Keragala CB, Markus HS, Werring DJ, Cloud GC, Medcalf RL. Cerebral Amyloid Angiopathy and the Fibrinolytic System: Is Plasmin a Therapeutic Target? Stroke 2021; 52:2707-2714. [PMID: 34126761 DOI: 10.1161/strokeaha.120.033107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cerebral amyloid angiopathy is a devastating cause of intracerebral hemorrhage for which there is no specific secondary stroke prevention treatment. Here we review the current literature regarding cerebral amyloid angiopathy pathophysiology and treatment, as well as what is known of the fibrinolytic pathway and its interaction with amyloid. We postulate that tranexamic acid is a potential secondary stroke prevention treatment agent in sporadic cerebral amyloid angiopathy, although further research is required.
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Affiliation(s)
- Chloe A Mutimer
- Department of Neurology, Alfred Hospital, Melbourne, Australia (C.A.M., G.C.C.)
| | - Charithani B Keragala
- Australian Centre for Blood Diseases (C.B.K., R.L.M.), Monash University, Melbourne, Australia
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neuroscience, University of Cambridge, United Kingdom (H.S.M.)
| | - David J Werring
- Stroke Research Centre, Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Australia (C.A.M., G.C.C.).,Department of Clinical Neuroscience, Central Clinical School (G.C.C.), Monash University, Melbourne, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases (C.B.K., R.L.M.), Monash University, Melbourne, Australia
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Hastings S, Myles PS, Medcalf RL. Plasmin, Immunity, and Surgical Site Infection. J Clin Med 2021; 10:2070. [PMID: 34065949 PMCID: PMC8150767 DOI: 10.3390/jcm10102070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022] Open
Abstract
SSI are a universal economic burden and increase individual patient morbidity and mortality. While antibiotic prophylaxis is the primary preventative intervention, these agents are not themselves benign and may be less effective in the context of emerging antibiotic resistant organisms. Exploration of novel therapies as an adjunct to antimicrobials is warranted. Plasmin and the plasminogen activating system has a complex role in immune function. The immunothrombotic role of plasmin is densely interwoven with the coagulation system and has a multitude of effects on the immune system constituents, which may not always be beneficial. Tranexamic acid is an antifibrinolytic agent which inhibits the conversion of plasminogen to plasmin. Clinical trials have demonstrated a reduction in surgical site infection in TXA exposed patients, however the mechanism and magnitude of this benefit is incompletely understood. This effect may be through the reduction of local wound haematoma, decreased allogenic blood transfusion or a direct immunomodulatory effect. Large scale randomised clinical trial are currently being undertaken to better explain this association. Importantly, TXA is a safe and widely available pharmacological agent which may have a role in the reduction of SSI.
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Affiliation(s)
- Stuart Hastings
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC 3004, Australia;
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Draxler DF, Medcalf RL. Fibrinolysis and tranexamic acid: mechanistic principles. ANZ J Surg 2021; 90:410-411. [PMID: 32339417 DOI: 10.1111/ans.15541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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The effect of multiple-dose oral versus intravenous tranexamic acid in reducing postoperative blood loss and transfusion rate after adolescent scoliosis surgery: a randomized controlled trial. Spine J 2021; 21:312-320. [PMID: 33049411 DOI: 10.1016/j.spinee.2020.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Tranexamic acid (TXA) is widely used in surgery for adolescent idiopathic scoliosis (AIS) and has been proved to be efficacious in reducing intraoperative blood loss (IBL) and the transfusion rate. However, the routine TXA regimen was intraoperative administration alone, in which the concentration of TXA could not cover the whole process of hyperfibrinolysis. And, its ability to control the massive postoperative blood loss (PBL) may be insufficient. Thus, we promoted a multiple-dose regimen of TXA for patients with AIS who underwent surgical correction. PURPOSE The primary aims were (1) to determine whether the multiple-dose regimen of TXA could reduce PBL and the postoperative transfusion rate, and (2) to compare the efficacy of oral administration with intravenous administration. The secondary aims were (3) to evaluate whether this regimen could alleviate inflammatory response, and (4) to assess the occurrence of drug-related side effects. STUDY DESIGN Prospective, double-blinded, randomized controlled trial. PATIENT SAMPLE A total of 108 patients with AIS who underwent posterior scoliosis correction and spinal fusion (PSS) were enrolled in this study. OUTCOME MEASURES The primary parameters were PBL and postoperative transfusion rate. Other parameters such as total blood loss (TBL), maximum hemoglobin (Hb) decrease, volume of drainage, inflammation markers (interleukin-6 [IL-6] and C-reactive protein [CRP]), and occurrence of complications were also collected and compared. Multiple regression analysis was used to examine the variables that affected PBL. METHODS Patients were randomized into three groups. All patients received intravenous TXA 50 mg/kg loading dose and 10 mg/kg/h maintenance dose during surgery. Group A received 1 g oral TXA at 4 hours, 10 hours, and 16 hours postoperatively; group B received 0.5 g intravenous TXA at 6 hours, 12 hours, and 18 hours postoperatively; group C received placebo. RESULTS The mean PBL and postoperative transfusion rate in group A (957.8±378.9 mL, 13.89%) and B (980.3±491.8 mL, 11.11%) were significantly lower than those in group C [1,495.9±449.6 mL, mean differences=538.1 mL, 95% confidence interval (CI), 290.1-786.1 mL, p<0.001; 515.6 mL, 95% CI, 267.6-763.6 mL, p<.001]; (36.11%, p=.029, p=.013). Meanwhile, the mean TBL, maximum Hb decrease, and volume of drainage were also significantly lower in group A and B than in group C. IL-6 and CRP in group A and B were significantly lower than in group C from postoperative days 1 to 3. All these differences were not significant between groups A and B. No drug-related complications were observed in any patient. Multiple regression showed that the application of postoperative TXA and number of screws were significant parameters affecting PBL. CONCLUSIONS A multiple-dose regimen of TXA, either by oral or intravenous application, could be a safe and effective means of controlling PBL and decreasing the postoperative transfusion rate in patients with AIS who underwent scoliosis surgery. In addition, it could inhibit postoperative inflammatory response.
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Heissig B, Salama Y, Takahashi S, Osada T, Hattori K. The multifaceted role of plasminogen in inflammation. Cell Signal 2020; 75:109761. [PMID: 32861744 PMCID: PMC7452830 DOI: 10.1016/j.cellsig.2020.109761] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 01/01/2023]
Abstract
A fine-tuned activation and deactivation of proteases and their inhibitors are involved in the execution of the inflammatory response. The zymogen/proenzyme plasminogen is converted to the serine protease plasmin, a key fibrinolytic factor by plasminogen activators including tissue-type plasminogen activator (tPA). Plasmin is part of an intricate protease network controlling proteins of initial hemostasis/coagulation, fibrinolytic and complement system. Activation of these protease cascades is required to mount a proper inflammatory response. Although best known for its ability to dissolve clots and cleave fibrin, recent studies point to the importance of fibrin-independent functions of plasmin during acute inflammation and inflammation resolution. In this review, we provide an up-to-date overview of the current knowledge of the enzymatic and cytokine-like effects of tPA and describe the role of tPA and plasminogen receptors in the regulation of the inflammatory response with emphasis on the cytokine storm syndrome such as observed during coronavirus disease 2019 or macrophage activation syndrome. We discuss tPA as a modulator of Toll like receptor signaling, plasmin as an activator of NFkB signaling, and summarize recent studies on the role of plasminogen receptors as controllers of the macrophage conversion into the M2 type and as mediators of efferocytosis during inflammation resolution.
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Affiliation(s)
- Beate Heissig
- Department of Immunological Diagnosis, Juntendo University, School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan.
| | - Yousef Salama
- An-Najah Center for Cancer and Stem Cell Research, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine.
| | - Satoshi Takahashi
- Department of Hematology, The Institute of Medical Science, The University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo 108-8639, Japan.
| | - Taro Osada
- Department of Gastroenterology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu-shi, 279-0021 Chiba, Japan.
| | - Koichi Hattori
- Center for Genomic & Regenerative Medicine, Juntendo University, School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan.
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Daglas M, Galle A, Draxler DF, Ho H, Liu Z, Sashindranath M, Medcalf RL. Sex-dependent effects of tranexamic acid on blood-brain barrier permeability and the immune response following traumatic brain injury in mice. J Thromb Haemost 2020; 18:2658-2671. [PMID: 32668057 DOI: 10.1111/jth.15015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an anti-fibrinolytic agent used to reduce bleeding in various conditions including traumatic brain injury (TBI). As the fibrinolytic system also influences the central nervous system and the immune response, TXA may also modulate these parameters following TBI. OBJECTIVES To determine the effect of TXA on blood-brain barrier (BBB) integrity and changes in immune and motor function in male and female mice subjected to TBI. METHODS Wild-type and plasminogen deficient (plg-/-) mice were subjected to TBI then administered either TXA/vehicle. The degree of BBB breakdown, intracerebral hemorrhage (ICH), motor dysfunction, and changes in inflammatory subsets in blood and brain were determined. RESULTS AND CONCLUSIONS Tranexamic acid significantly reduced BBB breakdown, and increased blood neutrophils in male mice 3 hours post-TBI. In contrast, TXA treatment of female mice increased BBB permeability and ICH but had no effect on blood neutrophils at the same time-point. TXA improved motor function in male mice but still increased BBB breakdown in female mice 24 hours post-TBI. Brain urokinase-type plasminogen activator (u-PA) antigen and activity levels were significantly higher in injured females compared to males. Because TXA can promote a pro-fibrinolytic effect via u-PA, these sex differences may be related to brain u-PA levels. TXA also increased monocyte subsets and dendritic cells in the injured brain of wild-type male mice 1 week post-TBI. Plg-/- mice of both sexes had reduced BBB damage and were protected from TBI irrespective of treatment indicating that TXA modulation of the BBB is plasmin-dependent. In conclusion, TXA is protective post-TBI but only in male mice.
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Affiliation(s)
- Maria Daglas
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Adam Galle
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zikou Liu
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Maithili Sashindranath
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Spinella PC, Thomas KA, Turnbull IR, Fuchs A, Bochicchio K, Schuerer D, Reese S, Coleoglou Centeno AA, Horn CB, Baty J, Shea SM, Meledeo MA, Pusateri AE, Levy JH, Cap AP, Bochicchio GV. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol 2020; 11:2085. [PMID: 33013880 PMCID: PMC7506112 DOI: 10.3389/fimmu.2020.02085] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The hemostatic properties of tranexamic acid (TXA) are well described, but the immunological effects of TXA administration after traumatic injury have not been thoroughly examined. We hypothesized TXA would reduce monocyte activation in bleeding trauma patients with severe injury. Methods This was a single center, double-blinded, randomized controlled trial (RCT) comparing placebo to a 2 g or 4 g intravenous TXA bolus dose in trauma patients with severe injury. Fifty patients were randomized into each study group. The primary outcome was a reduction in monocyte activation as measured by human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes 72 h after TXA administration. Secondary outcomes included kinetic assessment of immune and hemostatic phenotypes within the 72 h window post-TXA administration. Results The trial occurred between March 2016 and September 2017, when data collection ended. 149 patients were analyzed (placebo, n = 50; 2 g TXA, n = 49; 4 g TXA, n = 50). The fold change in HLA-DR expression on monocytes [reported as median (Q1–Q3)] from pre-TXA to 72 h post-TXA was similar between placebo [0.61 (0.51–0.82)], 2 g TXA [0.57 (0.47–0.75)], and 4 g TXA [0.57 (0.44–0.89)] study groups (p = 0.82). Neutrophil CD62L expression was reduced in the 4 g TXA group [fold change: 0.73 (0.63–0.97)] compared to the placebo group [0.97 (0.78–1.10)] at 24 h post-TXA (p = 0.034). The fold decrease in plasma IL-6 was significantly less in the 4 g TXA group [1.36 (0.87–2.42)] compared to the placebo group [0.46 (0.19–1.69)] at 72 h post-TXA (p = 0.028). There were no differences in frequencies of myeloid or lymphoid populations or in classical complement activation at any of the study time points. Conclusion In trauma patients with severe injury, 4 g intravenous bolus dosing of TXA has minimal immunomodulatory effects with respect to leukocyte phenotypes and circulating cytokine levels. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02535949.
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Affiliation(s)
- Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Kimberly A Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Isaiah R Turnbull
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Anja Fuchs
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Kelly Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Douglas Schuerer
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Stacey Reese
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Adrian A Coleoglou Centeno
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher B Horn
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan M Shea
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - M Adam Meledeo
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Anthony E Pusateri
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, United States
| | - Andrew P Cap
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Grant V Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
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July J, Pranata R. Tranexamic acid is associated with reduced mortality, hemorrhagic expansion, and vascular occlusive events in traumatic brain injury - meta-analysis of randomized controlled trials. BMC Neurol 2020; 20:119. [PMID: 32252661 PMCID: PMC7133014 DOI: 10.1186/s12883-020-01694-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023] Open
Abstract
Background This systematic review and meta-analysis aimed to synthesize the latest evidence on the efficacy and safety of tranexamic acid (TXA) on traumatic brain injury (TBI). Methods We performed a systematic literature search on topics that compared intravenous TXA to placebo in patients with TBI up until January 2020 from several electronic databases. Results There were 30.522 patients from 7 studies. Meta-analysis showed that TXA was associated with reduced mortality (RR 0.92 [0.88, 0.97], p = 0.002; I2: 0%) and hemorrhagic expansion (RR 0.79 [0.64, 0.97], p = 0.03; I2: 0%). Both TXA and control group has a similar need for neurosurgical intervention (p = 0.87) and unfavourable Glasgow Outcome Scale (GOS) (p = 0.59). The rate for vascular occlusive events (p = 0.09), and its deep vein thrombosis subgroup (p = 0.23), pulmonary embolism subgroup (p = 1), stroke subgroup (p = 0.38), and myocardial infarction subgroup (p = 0.15) were similar in both groups. Subgroup analysis on RCTs with low risk of bias showed that TXA was associated with reduced mortality and hemorrhagic expansion. TXA was associated with reduced vascular occlusive events (RR 0.85 [0.73, 0.99], p = 0.04; I2: 4%). GRADE was performed for the RCT with low risk of bias subgroup, it showed a high certainty of evidence for lower mortality, less hemorrhage expansion, and similar need for neurosurgical intervention in TXA group compared to placebo group. Conclusion TXA was associated with reduced mortality and hemorrhagic expansion but similar need for neurosurgical intervention and unfavorable GOS. Vascular occlusive events were slightly lower in TXA group on subgroup analysis of RCTs with low risk of bias.
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Affiliation(s)
- Julius July
- Department of Neurosurgery, Medical Faculty of Pelita Harapan University, Lippo Village Tangerang, Neuroscience Centre Siloam Hospital, Lippo Village, Tangerang, Indonesia.
| | - Raymond Pranata
- Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia
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