Comparative Efficacy of Perioperative Blood Conservation Agents in Pediatric Cranial Vault Remodeling: A Systematic Review and Network Meta-Analysis.
- 2025-10-15
- Neurosurgery 98(3)
- Christopher C Padilla
- Michael Farid
- Parker Smith
- Kwadwo Darko
- Kwadwo Darko
- Sean O'Leary
- Bennett Levy
- Umaru Barrie
- Hammad Khan
- Salah G Aoun
- David H Harter
- PubMed: 41090904
- DOI: 10.1227/neu.0000000000003798
Study Design
- Type
- Meta-Analysis
- Sample size
- n = 1,072
- Population
- 1072 pediatric patients undergoing cranial vault remodeling (mean age 15.6 months, weight 8.78 kg)
- Methods
- Systematic review and network meta-analysis of studies on blood conservation agents (tranexamic acid, aminocaproic acid, aprotinin, erythropoietin, iron) in pediatric CVR
Background and objectives
Red blood cell transfusions are commonly required in pediatric cranial vault remodeling (CVR); however, they carry risks and potential complications. This study evaluates the evidence on perioperative blood conservation agents assessing their efficacy in optimizing and reducing transfusion requirements in CVR.Methods
A systematic review was conducted using PubMed/MEDLINE, Scopus, Embase, Web of Sciences, and Google Scholar according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess articles discussing blood conservation agents in pediatric CVR. A network meta-analysis compared the effectiveness of different agents including tranexamic acid (TXA), aminocaproic acid (ACA), aprotinin, erythropoietin (EPO), and iron.Results
Sixteen studies analyzing 1072 patients with a mean age of 15.6 months and weight of 8.78 kg were included. The most reported craniosynostosis subtypes were sagittal (30.2%) and metopic (13.8%). TXA and ACA were independently associated with lower transfusion rates and volumes compared with placebo (ACA: odds ratio [OR], 0.25; 95% CI, 0.08-0.80; TXA: OR, 0.17; 95% CI, 0.07-0.42). Combination therapy with TXA + EPO + iron (OR: 0.004, 95% CI: 0.002-0.10) or ACA + EPO (OR: 0.04, 95% CI: 0.01-0.32) were associated with reductions in transfusion rates. Network meta-analysis ranking revealed TXA + EPO + iron (Surface Under the Cumulative Ranking and ACA + EPO (SUCRA: 75.41%) as the most effective treatments for reducing transfusion rates. While TXA was associated with significant reductions in blood loss compared with placebo (standard mean difference: -1.26, 95% CI: -1.97 to -0.56), ACA ranked highest for blood loss reduction (ACA: SUCRA, 84.58% vs TXA: SUCRA, 72.43%). Combination of TXA + EPO + iron was associated with significantly reduced hospital length of stay (standard mean difference: -1.00, 95% CI: -1.71 to -0.29). No treatment significantly affected the duration of surgery, and there were no reported treatment-associated thromboembolic events.Conclusion
Our meta-analysis reveals that TXA + ACA reduce red blood cell transfusion rates and volumes, with TXA + EPO + iron and ACA + EPO being most effective. This highlights the superiority of combination therapies and underscores the need for structured multimodal protocols in perioperative blood conservation for pediatric CVR.Research Insights
No treatment significantly affected the duration of surgery
- Effect
- Neutral
- Effect size
- Small
Combination of TXA + EPO + iron was associated with significantly reduced hospital length of stay (standard mean difference: -1.00, 95% CI: -1.71 to -0.29).
- Effect
- Beneficial
- Effect size
- Large
Combination therapy with TXA + EPO + iron (OR: 0.004, 95% CI: 0.002-0.10) or ACA + EPO (OR: 0.04, 95% CI: 0.01-0.32) were associated with reductions in transfusion rates.
- Effect
- Beneficial
- Effect size
- Large
Combination therapy with TXA + EPO + iron (OR: 0.004, 95% CI: 0.002-0.10) ... were associated with reductions in transfusion rates.
- Effect
- Beneficial
- Effect size
- Large