Transfusion Thresholds in Patients With Neurological Injury: Balancing Oxygen Delivery and Risk

Transfusion strategies in neurocritical care require a delicate and nuanced balance between optimizing oxygen delivery to the injured brain and minimizing transfusion-associated risks. Although restrictive transfusion protocols are widely adopted in critical care, their applicability to patients with neurological injury remains the subject of debate. Anemia may exacerbate cerebral hypoxia, potentially worsening neurological outcomes, yet transfusion carries risks such as thrombosis, immune modulation, and increased intracranial pressure. Studies comparing liberal and restrictive transfusion strategies in neurocritical care have yielded mixed results, with most settling on the noninferiority of a restrictive approach while still considering a higher threshold for particular subgroups. This focused review will examine the current evidence on transfusion strategies in neurocritically ill patients and highlight key areas for future research.