Aneurysmal subarachnoid hemorrhages may result in severe neurological problems with fatality rates reaching as high as 67%, particularly in patients with anemia. Increased oxygen delivery to the brain may improve neurological outcomes. According to recent studies, patients with brain injuries or hemorrhages may benefit from more liberal transfusion thresholds compared to most other patients. The Subarachnoid Hemorrhage Red Cell Transfusion Strategies and Outcome (SAHARA) trial, however, found no difference in liberal compared to restrictive transfusion thresholds for patients with aneurysmal subarachnoid hemorrhages. Briefly, 742 patients with subarachnoid hemorrhages and anemia (hemoglobin [Hb] <10 g/dL, 82% female, mean age 60 years) were randomized 1:1 at 23 centers across Canada, Australia and the U.S. to receive RBC transfusions at either a liberal threshold (Hb<10 g/dL) or restrictive threshold (Hb<8 g/dL). Over 99% of the patients in the liberal arm received RBC transfusions (median of 2 units) compared to 35% in the restrictive arm (median of 0 units). At 12 months, no differences were observed in neurological outcomes or quality of life scores between the study arms. Severe disability or death (modified Rankin scale score ≥4) occurred in 34% (122/364) of patients in the liberal arm and 38% (136/361) in the restrictive arm, while mortality was 27% in both groups. While these results suggest that a liberal transfusion threshold does not reduce unfavorable outcomes in patients with aneurysmal subarachnoid hemorrhage, further studies are needed to confirm these results.
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