Methodology: 4/5
Usefulness: 3/5
English SW, et al. N Engl J Med. 2025 Mar 13;392(11):1079-1088. doi: 10.1056/NEJMoa2410962.
Question and Methods: This multicenter RCT assessed whether a liberal (Hgb≤100 g/L) versus restrictive (Hgb≤80 g/L) transfusion strategy improved neurologic outcomes in patients with aneurysmal SAH (aSAH) and anemia.
Findings: At 12 months, there was no significant difference in unfavorable neurologic outcomes (33.5% vs. 37.7%; RR 0.88, p = 0.22, defined as modified Rankin Scale ≥4) or adverse transfusion events between groups.
Limitations: The open-label design, limited statistical power, and lack of standardized co-interventions, while enhancing generalizability, may have influenced the outcomes.
Interpretation: The TRAIN trial (Taccone et al., 2024) and trend based on this study support liberal transfusion strategy in aSAH. Further research is needed.
JC Supervisor: Dr. Venkatesh Thirugansambandamoorthy
This is an excellent study to review and present in a journal club. Honestly, I believe the impact of this study is quite regional. Since I began working in Saudi Arabia in 2008, I have yet to encounter a single case of aneurysmal or spontaneous subarachnoid hemorrhage. This may reflect underreporting, but I doubt that’s the main reason.
When I reviewed the literature on the prevalence of subarachnoid hemorrhage in our region, I found only one study reporting an incidence of 2.5 cases per 100,000 people in Jeddah—a figure similar to that reported in Qatar. By contrast, the prevalence in countries like Finland and Japan is strikingly higher: approximately 16 and 22 cases per 100,000, respectively.
For regions with higher incidence, this study will likely have a significant impact on policy and practice. In our setting, however, the rarity of the condition means it won’t change protocols. Still, given the devastating nature of aSAH, studies like this should refine our clinical judgment and be considered carefully when managing the few cases we do encounter.