Comparing the safety and efficacy of low-dose versus high-dose tranexamic acid in reducing blood loss in neurosurgical procedures: A systematic review and meta-analysis

Background: Perioperative bleeding is a major concern in neurosurgery, including spine fusions and cranial tumor resections. Tranexamic acid (TXA) is commonly used to reduce blood loss, but the ideal dosing strategy remains controversial. High-dose TXA regimens may enhance hemostasis but raise safety concerns, whereas low-dose regimens are commonly used with unclear comparative efficacy. This review aimed to compare the safety and efficacy of low-dose versus high-dose TXA in neurosurgical procedures. Methods: A comprehensive search of PubMed, Web of Science, and Google Scholar through January 2026 identified studies comparing TXA dosing in neurosurgery. Randomized controlled trials (RCTs) and observational studies reporting at least one relevant outcome were included. Results: Intraoperative blood loss is the primary outcome. Moreover, total blood loss, length of hospital stay, and duration of the surgery were secondary outcomes. The quality of the included studies was assessed using risk of bias 2 for RCTs and Methodological Index for Non-Randomized Studies for non-randomized studies. Meta-analysis was performed where appropriate. Eleven studies met inclusion criteria, with seven included in quantitative synthesis. Both low- and high-dose TXA significantly reduced perioperative blood loss compared with no TXA. However, no statistically significant differences were observed across the outcomes. No increase in thromboembolic events, seizures, or other major complications was observed with high-dose TXA. Conclusion: Both dosing strategies of TXA reduced blood loss effectively. Current evidence does not demonstrate a clear advantage of high-dose over low-dose TXA. However, given the limited direct comparative evidence, further high-quality randomized trials are needed to define the optimal dosing strategy.