Liberal transfusion strategy not beneficial in treating aneurysmal subarachnoid hemorrhage

1. Among critically ill adults with acute aneurysmal subarachnoid hemorrhage (SAH) and anemia, a liberal transfusion strategy did not improve neurologic outcomes by 12 months compared to a restrictive strategy.

2. The incidence of adverse events and quality of life ratings also did not differ between the two groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: SAH resulting from intracranial aneurysm rupture is a critical condition, with a high risk of death and disability from neurologic injury. Anemia is common in SAH and associated with adverse clinical outcomes, due to impaired oxygen delivery. Red blood cell transfusion may improve oxygen delivery, but existing evidence is lacking and equivocal regarding the transfusion threshold and strategy for optimal clinical outcomes. This open-label randomized trial compared a liberal transfusion strategy (hemoglobin threshold ≤10g/dL) against a restrictive strategy (threshold ≤8g/dL) in critically ill patients with acute aneurysmal SAH. By 12 months, the liberal-strategy group did not differ from the restrictive-strategy group in the incidence of neurologic outcome, functional independence, or quality of life. The rates of adverse events were also comparable between the two groups. The study was limited by its open-label design, although outcome assessment was blinded, and suboptimal assessment of certain secondary outcomes. Nevertheless, these results suggested that a liberal transfusion strategy did not result in improved clinical outcomes compared to a restrictive strategy in critically ill patients with aneurysmal SAH.

Click here to read the study in NEJM

Relevant Reading: Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury

In-Depth [randomized controlled trial]: This study was a pragmatic, open-label, randomized controlled trial conducted at 23 neurocritical care centers in Canada, Australia, and the United States. It compared a liberal transfusion strategy against a restrictive strategy to treat anemia in patients with aneurysmal SAH. Patients aged 18 or above with aneurysmal SAH and a hemoglobin level ≤10/dL within 10 days of admission were eligible for inclusion. Exclusion criteria included non-aneurysmal SAH, active bleeding causing hemodynamic instability, and contraindications or objections to blood transfusion. In total, 742 patients were randomly assigned 1:1 to either a liberal transfusion strategy (mandatory transfusion at hemoglobin ≤10g/dL) or a restrictive strategy (optional transfusion at hemoglobin ≤8g/dL). The primary outcome was an unfavorable neurologic outcome at 12 months. Secondary outcomes included functional independence (measured by Functional Independence Measure [FIM]), quality of life (measured by EuroQol five-dimension, five-level [EQ-5D-5L] index and a visual analog scale [VAS]), and mortality. At 12 months, unfavorable neurologic outcomes occurred in 33.5% of the liberal-strategy group and 37.7% of the restrictive-strategy group (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.72-1.09, p=0.22). The FIM Score was 82.8±54.6 for the liberal-strategy group and 79.8±54.5 for the restrictive-strategy group (mean difference [MD] 3.01, 95% CI -5.49 to 11.51). Regarding quality of life, there was no difference in the EQ-5D-5L utility index (MD 0.02, 95% CI -0.04 to 0.09) and VAS score (MD 2.08, 95% CI -3.76 to 7.93). Mortality was also comparable between the groups (RR 0.99, 95% CI 0.7701.28). Overall, the results did not show a benefit of a liberal transfusion strategy over a restrictive one in improving neurological outcomes at 12 months in critically ill patients with aneurysmal SAH.

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