Liberal vs Restrictive Blood Transfusion Strategies in Neurocritical Care With Acute Brain Injury: A Systematic Review and Meta-analysis of Randomized Controlled Trials
Noor Naeem1, Ayesha Shaukat2, Muhammad Ahmed2, Komal Khan3, Aiman Shahid Khan2, Rubaisha Saleem2, Anupama Ariyasiri4, Syed Abdul Aziz Jameel4, Shahab Afridi5, Javeria Salman6, Marib Ashraf1, Amamah Chaudhry1, Zobia Ahmad2, Muhammad Omar Larik7, Muhammad Hasanain2, Muhammad Umair Anjum8, Anoosh Farooqui9
1Department of Medicine, Rashid Latif Medical College, Lahore, Pakistan, 2Department of Medicine, Dow Medical College, Karachi, Pakistan, 3Department of Medicine, Ziauddin University, Karachi, Pakistan, 4Department of Medicine, Dow International Medical College, Karachi, Pakistan, 5Department of Medicine, Ayub Medical College, Abbottabad, Pakistan, 6Department of Medicine, Dow Medical College,Karachi,Pakistan, 7Department of Medicine, Dow International Medical College, 8Department of Medicine, The Wright Medical Centre, Scranton, Pennsylvania, 9Master of Public Health, Michigan State University, USA
Objective:
To compare the effects of restrictive versus liberal transfusion thresholds on mortality, neurological outcomes, and complications in adult neurocritical care patients.
Background:
Neurocritical patients with traumatic brain injury, subarachnoid hemorrhage, or intracerebral hemorrhage often develop anemia that compromises brain oxygen delivery and worsens outcomes. Both liberal and restrictive blood transfusion strategies are used to manage anemia in these patients, but the optimal approach remains unclear due to inconsistent evidence and limited neuro-specific analyses.
Design/Methods:
A systematic search of PubMed, Cochrane Library, ScienceDirect, and Google Scholar (inception–December 2024) identified randomized controlled trials comparing restrictive and liberal transfusion strategies in adult neurocritical care, following PRISMA guidelines. Outcomes included mortality, Glasgow Outcome Scale (GOS), transfusion volume, sepsis, ICU/hospital length of stay, and secondary complications. The study is registered with PROSPERO (CRD42025635426).
Results:
Seven randomized controlled trials including 1,941 neurocritical care patients were analyzed. Restrictive transfusion strategies significantly reduced transfusion requirements and sepsis risk without adversely impacting mortality or neurological outcomes. Patients in the restrictive group received fewer red blood cell (RBC) units (mean difference = 2.36; 95% CI 1.08–3.64; P = 0.0003) and had a lower incidence of sepsis (risk ratio = 0.73; 95% CI 0.56–0.96; P = 0.02). Mortality at ICU, in-hospital, 30-day, 6-month, and long-term follow-up, as well as GOS at six months, showed no significant differences (all P > 0.05). ICU and hospital length of stay and secondary neurological or systemic complications were comparable.
Conclusions:
Restrictive transfusion strategies are as effective as liberal approaches, achieving similar mortality and neurological outcomes while minimizing transfusion requirements and infection risk. Restrictive thresholds represent a safe, resource-efficient approach that preserves neurological outcomes and supports evidence-based transfusion practices. Future studies should identify patient-specific hemoglobin targets to optimize cerebral oxygenation and neurologic recovery.
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