Abstract
PURPOSE: To advocate for a Liberal Transfusion Strategy (LTS) in neurocritical care patients with Acute Brain Injury (ABI) and provide updated evidence for optimizing transfusion thresholds in clinical guidelines. BACKGROUND: Anemia frequently complicates ABI management, often necessitating red blood cell transfusions. However, the optimal hemoglobin (Hb) threshold for transfusion remains controversial. While earlier meta-analyses indicated no significant differences between LTS and restrictive transfusion strategies (RTS), emerging randomized controlled trials (RCTs) emphasize the need for reappraisal within neurocritical care. METHODS: This meta-analysis included five RCTs involving 2399 patients (1,191 LTS; 1208 RTS) with ABI (subarachnoid hemorrhage, traumatic brain injury, or intracerebral hemorrhage). LTS was defined as transfusion at Hb ≤ 10-9 g/dL, and RTS as transfusion at Hb ≤ 7-8 g/dL. Outcomes assessed included sepsis or septic shock, ICU mortality, unfavorable functional outcomes at six months, venous thromboembolism (VTE), acute respiratory distress syndrome (ARDS), and in-hospital mortality. RESULTS: RTS significantly increased the risk of sepsis or septic shock (relative risk [RR]: 1.42; 95% confidence interval [CI] 1.08-1.86; p = 0.01) and unfavorable functional outcomes at six months (RR 1.13; 95% CI 1.06-1.21; p = 0.0003). No significant differences were observed in ICU mortality (RR 1.00; 95% CI 0.84-1.20; p = 0.96), VTE (RR: 0.88; 95% CI 0.56-1.38; p = 0.58), ARDS (RR 1.05; 95% CI 0.69-1.61; p = 0.81), or in-hospital mortality (RR 0.98; 95% CI 0.76-1.26; p = 0.89). Heterogeneity was minimal (I(2) < 25%). CONCLUSION: LTS demonstrates the potential to enhance safety and functional recovery in ABI patients by mitigating sepsis risk and promoting favorable neurologic outcomes. Further high-powered RCTs are warranted to validate these findings and refine transfusion protocols.