Closing the evidence gap: Evaluating tranexamic acid for traumatic brain injury in a resource-limited setting

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in Low- and Middle-Income Countries (LMICs). Prior clinical trials suggest early tranexamic acid (TXA) may reduce mortality, with effects varying by TBI severity; however, evidence in LMICs remains limited. TBI patients (Abbreviated Injury Scale (AIS) Head Severity ≥2) in Western Cape, South Africa who presented within 3 hours of injury were included. Severe hemorrhage, significant non-head injuries (AIS Body ≥3), or receipt of blood products or TXA after 3 hours were excluded. TXA within 3 hours defined treatment, whereas controls did not receive TXA. An adjusted analysis on 7-day mortality (primary outcome) as well as at 72-hours, 30 days, and discharge neurologic status was performed. Subgroup analyses evaluated injury type, TBI severity, TXA timing, and dose. 1794 patients were included, 144 (8%) received TXA. After adjustment, TXA administration was associated with lower odds of 72-hour mortality (marginal odds ratio [mOR] =0.75, 95% confidence interval [CI] 0.44-1.26) and 7-day mortality (mOR=0.75, 95% CI 0.43-1.32), although not significant. Patients with severe TBI (GCS <8) had lower 72-hour odds of mortality (mOR=0.54, 95% CI 0.31-0.94) and 7-day (mOR=0.47, 95% CI 0.26-0.83). Subgroup and sensitivity analyses demonstrated no significant differences in 7-day mortality by injury type, TXA timing, or dose. TXA was associated with significantly lower 72-hour and 7-day mortality in severe TBI, and statistically nonsignificant large reductions in mortality in the general cohort. Our findings add to the limited evidence that TXA may benefit patients with severe TBI in resource-limited settings.