Mitchell S.V. Elkind, M.D., is American Heart Association president-elect, chair of the Advisory Committee of the American Stroke Association — a division of the American Heart Association and professor of neurology and epidemiology at Columbia University New York. 

copyright American Heart Association

"In this trial, the investigators were attacking a problem that's been a really difficult one for the stroke community. And that's the problem of interest cerebral hemorrhage. We've gotten pretty good at treating Ischemic stroke, especially in these early time windows. And we know that we can can reduce the size of a stroke and improve patient outcomes with thrombolytic therapy in the setting of Ischemic stroke. We haven't yet cracked that nut of how to reduce bleeding in patients who initially present with a hemorrhage. And this is one way actually in which stroke is so different from cardiac disease. 

People don't have hemorrhagic heart attacks, but they do have hemorrhagic strokes. And so we've really been pretty limited to supportive care, when managing these patients. We can treat their blood pressure, We can manage the complications, but people have been searching for a way to stop the bleeding in its tracks in a patient who's got cardiac cerebral hemorrhage. There have been some suggestions from other studies in the past that certain agents that limit bleeding can help to reduce the size of the hemorrhage, but they haven't yet shown benefits in terms of clinical outcomes. And so the investigators in this trial of a stop asked study tested whether a certain agent, antifibrinolytic agent called Tranexamic Acid or TXA could be used to stop bleeding.

And importantly, what they did was they chose a group of patients who had evidence of ongoing bleeding so we can see from a CT angiogram, of the evidence of ongoing bleeding on that scan, it's called the spot sign. So they took patients who specifically had evidence of a spot sign and then randomize them to getting this agent or not within just a few hours of their hemorrhage of their onset of clinical symptoms. And they found some suggestive evidence of a benefit, there seem to be some evidence that they could reduce the risk of ongoing bleeding and the hematoma volume, but the results were not statistically significant. 

In a secondary analysis, though, where they looked at just those patients who got treated within the first two hours after their hemorrhage presumably began, there was in fact some some further evidence of benefit. But because that's a secondary analysis, it really just sets the stage for future studies, and that kind of hyper acute period to see if the bleeding can be arrested. So in a sense of very exciting result because it suggests that we may be able to have an impact, although from a practical level, it means we have to get to those patients super early, perhaps even earlier than we're accustomed to doing for Ischemic stroke patients. And that I think is gonna be the big challenge with a lot of these therapies.

I think a big reason for these kinds of results in the setting of hemorrhage is that, very quickly after the hemorrhage begins and the hematoma expands a bit, a lot of damage may already have occurred. And so even if we stop the bleeding later, much of the injury has occurred, and it may just be a bit too late. But the proof of principle is there. We can arrest the bleeding and in some patients who have evidence of ongoing bleeding, and this I think, will lead to a lot of excitement and a lot of future studies as well."