Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study

Chahnez Taleb; Elisa Gouvea Bogossian; Carla Bittencour Rynkowski; Kirsten Møller; Piet Lormans; Manuel Quintana Diaz; Anselmo Caricato; Luigi Zattera; Pedro Kurtz; Geert Meyfroidt; Herve Quintard; Maria Celeste Dias; Angelo Giacomucci; Charlotte Castelain; Russell Chabanne; Pilar Marcos-Neira; Stepani Bendel; Ahmed Subhy Alsheikhly; Mohamed Elbahnasawy; Samuel Gay; Maximilian D'Onofrio; Konstantin A Popugaev; Nikolaos Markou; Pierre Bouzat; Jean-Louis Vincent; Fabio Silvio Taccone; TRAIN Study Trial Group

doi:10.1186/s13054-025-05270-5

Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study

Chahnez Taleb, Elisa Gouvea Bogossian^*, Carla Bittencour Rynkowski, Kirsten Møller, Piet Lormans, Manuel Quintana Diaz, Anselmo Caricato, Luigi Zattera, Pedro Kurtz, Geert Meyfroidt, Herve Quintard, Maria Celeste Dias, Angelo Giacomucci, Charlotte Castelain, Russell Chabanne, Pilar Marcos-Neira, Stepani Bendel, Ahmed Subhy Alsheikhly, Mohamed Elbahnasawy, Samuel GayMaximilian D'Onofrio, Konstantin A Popugaev, Nikolaos Markou, Pierre Bouzat, Jean-Louis Vincent, Fabio Silvio Taccone, TRAIN Study Trial Group

^*Corresponding author for this work

Department of Neuroanaesthesiology

6 Citations (Scopus)

Abstract

BACKGROUND: The optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH.

METHODS: This is a pre-planned secondary analysis of the "TRansfusion Strategies in Acute brain INjured Patients" (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1-5.

RESULTS: Of the 190 SAH patients in the trial, 188 (98.9%) had data available for the primary outcome, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3%) patients in the liberal group and 78 (76.4%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95% confidence intervals, 95% CI 0.71-1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95% CI 0.41-0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95% CI 0.70-0.99).

CONCLUSIONS: A liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group.

TRIAL REGISTRATION: ClinicalTrials.gov number-NCT02968654 registered on November 16th, 2016.

Original language	English
Article number	67
Journal	Critical care (London, England)
Volume	29
Issue number	1
Number of pages	13
ISSN	1466-609X
DOIs	https://doi.org/10.1186/s13054-025-05270-5
Publication status	Published - 7 Feb 2025

Keywords

Humans
Subarachnoid Hemorrhage/therapy
Male
Female
Middle Aged
Aged
Adult
Erythrocyte Transfusion/methods
Treatment Outcome
Blood Transfusion/methods
Stroke
Anemia
Blood
Acute brain injury

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10.1186/s13054-025-05270-5Licence: CC BY-NC-ND

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Taleb, C., Gouvea Bogossian, E., Bittencour Rynkowski, C., Møller, K., Lormans, P., Quintana Diaz, M., Caricato, A., Zattera, L., Kurtz, P., Meyfroidt, G., Quintard, H., Dias, M. C., Giacomucci, A., Castelain, C., Chabanne, R., Marcos-Neira, P., Bendel, S., Alsheikhly, A. S., Elbahnasawy, M., ... TRAIN Study Trial Group (2025). Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study. Critical care (London, England), 29(1), Article 67. https://doi.org/10.1186/s13054-025-05270-5

Taleb, C, Gouvea Bogossian, E, Bittencour Rynkowski, C, Møller, K, Lormans, P, Quintana Diaz, M, Caricato, A, Zattera, L, Kurtz, P, Meyfroidt, G, Quintard, H, Dias, MC, Giacomucci, A, Castelain, C, Chabanne, R, Marcos-Neira, P, Bendel, S, Alsheikhly, AS, Elbahnasawy, M, Gay, S, D'Onofrio, M, Popugaev, KA, Markou, N, Bouzat, P, Vincent, J-L, Taccone, FS & TRAIN Study Trial Group 2025, 'Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study', Critical care (London, England), vol. 29, no. 1, 67. https://doi.org/10.1186/s13054-025-05270-5

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title = "Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study",

abstract = "BACKGROUND: The optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH.METHODS: This is a pre-planned secondary analysis of the {"}TRansfusion Strategies in Acute brain INjured Patients{"} (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1-5.RESULTS: Of the 190 SAH patients in the trial, 188 (98.9\%) had data available for the primary outcome, with 86 (45.3\%) in the liberal group and 102 (53.6\%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3\%) patients in the liberal group and 78 (76.4\%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95\% confidence intervals, 95\% CI 0.71-1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95\% CI 0.41-0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95\% CI 0.70-0.99).CONCLUSIONS: A liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group.TRIAL REGISTRATION: ClinicalTrials.gov number-NCT02968654 registered on November 16th, 2016.",

keywords = "Humans, Subarachnoid Hemorrhage/therapy, Male, Female, Middle Aged, Aged, Adult, Erythrocyte Transfusion/methods, Treatment Outcome, Blood Transfusion/methods, Stroke, Anemia, Blood, Acute brain injury",

author = "Chahnez Taleb and \{Gouvea Bogossian\}, Elisa and \{Bittencour Rynkowski\}, Carla and Kirsten M{\o}ller and Piet Lormans and \{Quintana Diaz\}, Manuel and Anselmo Caricato and Luigi Zattera and Pedro Kurtz and Geert Meyfroidt and Herve Quintard and Dias, \{Maria Celeste\} and Angelo Giacomucci and Charlotte Castelain and Russell Chabanne and Pilar Marcos-Neira and Stepani Bendel and Alsheikhly, \{Ahmed Subhy\} and Mohamed Elbahnasawy and Samuel Gay and Maximilian D'Onofrio and Popugaev, \{Konstantin A\} and Nikolaos Markou and Pierre Bouzat and Jean-Louis Vincent and Taccone, \{Fabio Silvio\} and \{TRAIN Study Trial Group\}",

note = "{\textcopyright} 2025. The Author(s).",

year = "2025",

month = feb,

day = "7",

doi = "10.1186/s13054-025-05270-5",

language = "English",

volume = "29",

journal = "Critical care (London, England)",

issn = "1466-609X",

publisher = "BioMed Central Ltd",

number = "1",

}

TY - JOUR

T1 - Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage

T2 - a secondary analysis of the TRAIN study

AU - Taleb, Chahnez

AU - Gouvea Bogossian, Elisa

AU - Bittencour Rynkowski, Carla

AU - Møller, Kirsten

AU - Lormans, Piet

AU - Quintana Diaz, Manuel

AU - Caricato, Anselmo

AU - Zattera, Luigi

AU - Kurtz, Pedro

AU - Meyfroidt, Geert

AU - Quintard, Herve

AU - Dias, Maria Celeste

AU - Giacomucci, Angelo

AU - Castelain, Charlotte

AU - Chabanne, Russell

AU - Marcos-Neira, Pilar

AU - Bendel, Stepani

AU - Alsheikhly, Ahmed Subhy

AU - Elbahnasawy, Mohamed

AU - Gay, Samuel

AU - D'Onofrio, Maximilian

AU - Popugaev, Konstantin A

AU - Markou, Nikolaos

AU - Bouzat, Pierre

AU - Vincent, Jean-Louis

AU - Taccone, Fabio Silvio

AU - TRAIN Study Trial Group

PY - 2025/2/7

Y1 - 2025/2/7

N2 - BACKGROUND: The optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH.METHODS: This is a pre-planned secondary analysis of the "TRansfusion Strategies in Acute brain INjured Patients" (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1-5.RESULTS: Of the 190 SAH patients in the trial, 188 (98.9%) had data available for the primary outcome, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3%) patients in the liberal group and 78 (76.4%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95% confidence intervals, 95% CI 0.71-1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95% CI 0.41-0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95% CI 0.70-0.99).CONCLUSIONS: A liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group.TRIAL REGISTRATION: ClinicalTrials.gov number-NCT02968654 registered on November 16th, 2016.

AB - BACKGROUND: The optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH.METHODS: This is a pre-planned secondary analysis of the "TRansfusion Strategies in Acute brain INjured Patients" (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1-5.RESULTS: Of the 190 SAH patients in the trial, 188 (98.9%) had data available for the primary outcome, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3%) patients in the liberal group and 78 (76.4%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95% confidence intervals, 95% CI 0.71-1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95% CI 0.41-0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95% CI 0.70-0.99).CONCLUSIONS: A liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group.TRIAL REGISTRATION: ClinicalTrials.gov number-NCT02968654 registered on November 16th, 2016.

KW - Humans

KW - Subarachnoid Hemorrhage/therapy

KW - Male

KW - Female

KW - Middle Aged

KW - Aged

KW - Adult

KW - Erythrocyte Transfusion/methods

KW - Treatment Outcome

KW - Blood Transfusion/methods

KW - Stroke

KW - Anemia

KW - Blood

KW - Acute brain injury

UR - https://www.scopus.com/pages/publications/85218359156

U2 - 10.1186/s13054-025-05270-5

DO - 10.1186/s13054-025-05270-5

M3 - Journal article

C2 - 39920710

SN - 1466-609X

VL - 29

JO - Critical care (London, England)

JF - Critical care (London, England)

IS - 1

M1 - 67

ER -

Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study

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Keywords

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