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Emergency care
Intracerebral haemorrhage is hard to stop, and must be attacked before, during and after
  1. David L Tirschwell
  1. Harborview Neurology, University of Washington, Seattle, Washington, USA
  1. Correspondence to Professor David L Tirschwell, University of Washington, Seattle WA 98104, USA; tirsch{at}

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Commentary on: Sprigg N, Flaherty K, Appleton JP, et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet 2018;391:2107–2115.


Intracerebral haemorrhage (ICH) is a substantial public health problem. While ischaemic stroke is commonly accepted as the majority of the burden of stroke, this is a western bias. In many Asian and lower-income countries, ICH represents an increased and even majority proportion of the stroke burden. Despite substantive advancements in the treatment of acute ischaemic stroke (eg, intravenous tissue plasminogen activator and mechanical thrombectomy), no acute interventions have been shown to be unequivocally effective for improving ICH outcomes. Given that much of the global burden of ICH occurs in lesser resourced environments, inexpensive and easily applied treatments for ICH are sorely needed.


TICH-2 was an international, placebo-controlled, blinded randomised trial in acute non-traumatic ICH, with last known well within 8 hours.1 The intervention was tranexamic acid …

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  • Contributors I alone wrote this comment.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Data sharing statement No original research here.