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The following is a summary of “Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study,” published in the February 2025 issue of Critical Care by Taleb et al. 

The ideal hemoglobin (Hb) threshold for initiating red blood cell transfusions (RBCT) in individuals with subarachnoid hemorrhage remains uncertain.  

Researchers conducted a retrospective study to assess the effects of liberal versus restrictive transfusion strategies on neurological outcomes in individuals with subarachnoid hemorrhage (SAH).  

They carried out a pre-planned secondary analysis of the “Transfusion Strategies in Acute Brain Injured Patients” (TRAIN) study. All individuals with SAH from the original trial were included. Participants were randomized to receive RBCT when Hb levels fell below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome measured was unfavorable neurological status at 180 days, defined by a Glasgow Outcome Scale Extended score of 1–5.  

The results showed that out of 190 individuals with SAH, 188 (98.9%) had primary outcome data, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. The liberal group was older but had similar baseline characteristics. The RBCT and Hb levels were higher in the liberal group. At 180 days, unfavorable outcomes were observed in 57 (66.3%) individuals in the liberal group and 78 (76.4%) in the restrictive group (risk ratio (RR) 0.87; 95% CI (0.71–1.04). The liberal group had a reduced risk of cerebral ischemia (RR 0.63; 95% CI 0.41–0.97). Multivariate analysis associated liberal group randomization with a lower risk of unfavorable outcomes (RR 0.83; 95% CI 0.70–0.99).  

Investigators concluded that a liberal transfusion strategy did not reduce unfavorable outcomes compared to a restrictive approach but was linked to a lower risk of unfavorable outcomes and cerebral ischemia after adjusting for confounders. 

Source: ccforum.biomedcentral.com/articles/10.1186/s13054-025-05270-5