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Tranexamic acid to reduce head injury death in people with traumatic brain injury: the CRASH-3 international RCT
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posted on 2023-06-10, 01:09 authored by Ian Roberts, Haleema Shakur-Still, Amy Aeron-Thomas, Danielle Beaumont, Antonio Belli, Amy Brenner, Madeleine Cargill, Rizwana Chaudhri, Nicolas Douglas, Lauren Frimley, Catherine Gilliam, Amber Geer, Zahra Jamal, Rashid Jooma, Raoul Mansukhani, Alec Miners, Jason Pott, Danielle Prowse, Temitayo Shokunbi, Jack WilliamsBackground Tranexamic acid safely reduces mortality in traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury and can cause brain herniation and death. We assessed the effects of tranexamic acid in traumatic brain injury patients. Objective To assess the effects of tranexamic acid on death, disability and vascular occlusive events in traumatic brain injury patients. We also assessed cost-effectiveness. Design Randomised trial and economic evaluation. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers and those assessing outcomes were masked to allocation. All analyses were by intention to treat. We assessed the cost-effectiveness of tranexamic acid versus no treatment from a UK NHS perspective using the trial results and a Markov model. Setting 175 hospitals in 29 countries. Participants Adults with traumatic brain injury within 3 hours of injury with a Glasgow Coma Scale score of =?12 or any intracranial bleeding on computerised tomography scan, and no major extracranial bleeding, were eligible. Intervention Tranexamic acid (loading dose 1?g over 10 minutes then infusion of 1?g over 8 hours) or matching placebo. Main outcome measures Head injury death in hospital within 28 days of injury in patients treated within 3 hours of injury. Secondary outcomes were early head injury deaths, all-cause and cause-specific mortality, disability, vascular occlusive events, seizures, complications and adverse events. Results Among patients treated within 3 hours of injury (n?=?9127), the risk of head injury death was 18.5% in the tranexamic acid group versus 19.8% in the placebo group (855/4613 vs. 892/4514; risk ratio 0.94, 95% confidence interval 0.86 to 1.02). In a prespecified analysis excluding patients with a Glasgow Coma Scale score of 3 or bilateral unreactive pupils at baseline, the results were 12.5% in the tranexamic acid group versus 14.0% in the placebo group (485/3880 vs. 525/3757; risk ratio 0.89, 95% confidence interval 0.80 to 1.00). There was a reduction in the risk of head injury death with tranexamic acid in those with mild to moderate head injury (166/2846 vs. 207/2769; risk ratio 0.78, 95% confidence interval 0.64 to 0.95), but in those with severe head injury (689/1739 vs. 685/1710; risk ratio 0.99, 95% confidence interval 0.91 to 1.07) there was no apparent reduction (p-value for heterogeneity?=?0.030). Early treatment was more effective in mild and moderate head injury (p?=?0.005), but there was no obvious impact of time to treatment in cases of severe head injury (p?=?0.73). The risk of disability, vascular occlusive events and seizures was similar in both groups. Tranexamic acid is highly cost-effective for mild and moderate traumatic brain injury (base case of £4288 per quality-adjusted life-year gained). Conclusion Early tranexamic acid treatment reduces head injury deaths. Treatment is cost-effective for patients with mild or moderate traumatic brain injury, or those with both pupils reactive. Future work Further trials should examine early tranexamic acid treatment in mild head injury. Research on alternative routes of administration is needed. Limitations Time to treatment may have been underestimated. Trial registration Current Controlled Trials ISRCTN15088122, ClinicalTrials.gov NCT01402882, EudraCT 2011-003669-14, Pan African Clinical Trial Registry PACTR20121000441277. Funding The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 26. See the NIHR Journals Library website for further project information. In addition, funding was provided by JP Moulton Charitable Trust, Joint Global Health Trials (Medical Research Council, Department for International Development and the Wellcome Trust). This project was funded by the NIHR Global Health Trials programme.
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- Published
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- Published version
Journal
Health Technology AssessmentISSN
1366-5278Publisher
NIHR Journals LibraryExternal DOI
Issue
26Volume
25Page range
VII-76Event location
EnglandDepartment affiliated with
- Psychology Publications
Full text available
- Yes
Peer reviewed?
- Yes
Legacy Posted Date
2021-09-24First Open Access (FOA) Date
2021-09-24First Compliant Deposit (FCD) Date
2021-09-24Usage metrics
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No categories selectedKeywords
Antifibrinolytic agentsblood pressurebrain injuriescomputedcost–benefit analysiscraniocerebral traumaglasgow comaglobal healthhemorrhageintensive care unitsintention-to-treat analysisintracranial hemorrhagesneurosurgeryquality-adjusted life-yearsstroketime to treatmenttomographytranexamic acidtraumatic
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