Following Acute Brain Injury, Poor Neurologic Outcomes May Be Less Likely With Liberal Transfusion Strategy

Patients with acute brain injury and anemia who were treated using a liberal transfusion strategy were less likely to experience poor neurologic outcomes compared with those who were treated using a more restrictive transfusion threshold, according the to the results of a phase III trial published in JAMA.

The Transfusion Strategies in Acute Brain Injured Patients (TRAIN) trial was an open-label randomized trial designed to assess the neurologic impact of different hemoglobin (Hb) thresholds — liberal or restrictive — in guiding red blood cell (RBC) transfusion in patients with acute brain injury that required admission to an intensive care unit (ICU).

The researchers found that 62.6% of patients in the liberal strategy group had an unfavorable neurological outcome compared with 72.6% in the restrictive strategy group.

Conducted in 72 ICUs across 22 countries, the TRAIN trial enrolled adults admitted to an ICU with traumatic brain injury (TBI), subarachnoid hemorrhage or intracerebral hemorrhage within 10 days of their initial injury. Neurologic function was assessed using the Glasgow Coma Scale Extended (GOS-E) score. Specifically, patients with a score of 13 or less on the day of randomization, along with an expected ICU stay of at least 3 days, and a Hb level of 9 g/dL or less were included in the study.

Enrolled patients were randomized in a 1:1 ratio to receive RBC transfusions at a Hb threshold of less than 7 g/dL (restrictive strategy group) or at less than 9 g/dL (liberal strategy group).

The primary outcome measure was the proportion of patients with unfavorable neurological outcome at 180 days after randomization, based on GOSE assessment. The scale is widely used to assess global disability and recovery after traumatic brain injury. For this study, the scores were broken down as unfavorable (score of 1-5) or favorable (score of 6-8).

A total of 397 patients were randomized to liberal transfusion strategy; 423 were included in the restrictive group. In all, 910 and 373 transfusions were administered in the liberal and restrictive strategy groups, respectively, during the study period. Almost half of patients in the restrictive group (48.5%) required transfusion, compared with 89.9% of patients in the liberal group.

Cerebral ischemic event was a prespecified adverse event of concern. The researchers found that cerebral ischemic events occurred in 8.8% and 13.5% of patients in the liberal and restrictive transfusion groups, respectively. However, there was no difference in 28-day survival or other prespecified adverse events between the liberal and restrictive strategy groups.

The findings add to those from the HEMOTION trial, which showed that a liberal transfusion strategy was associated with a reduction in the risk of unfavorable neurological outcomes at 6 months with a restrictive strategy, though this study was limited to patients with TBI alone.

Taken together, the two trials provide the best available evidence that “it is prudent to advocate a liberal transfusion strategy for these neurocritically ill patients,” Alexis F. Turgeon, MD, and François Lauzier, MD, concluded in a related editorial.