Highlights
• Discharge destination significantly influences long-term functional recovery after aneurysmal subarachnoid hemorrhage.
• Acute rehabilitation is associated with improved outcomes, particularly in patients with poor baseline World Federation of Neurosurgical Societies grading scale scores.
• An extended in-hospital stay, as indicated by discharge to another hospital facility, reduced the odds of long-term functional independence.
• The implementation of standardized discharge and rehabilitation pathways is essential to optimize clinical recovery after an aSAH.
Introduction
Aneurysmal subarachnoid hemorrhage (aSAH), the leading cause of non-traumatic subarachnoid hemorrhage, Reference Ingall, Asplund, Mähönen and Bonita1 generates high rates of morbidity and mortality globally. Reference Linn, Rinkel, Algra and Van Gijn2,Reference Nieuwkamp, Setz, Algra, Linn, De Rooij and Rinkel3 This condition often results in devastating neurological deficits and long-term disability, constituting a significant burden on both patients and healthcare systems. Reference Hop, Rinkel, Algra and Van Gijn4 Despite advancements in the medical and surgical management of patients with ruptured intracranial aneurysms (IAs), an elevated proportion of survivors of aSAH encounter persistent functional impairments, substantially diminishing their quality of life. Reference Hua, Gray and Wolstenholme5 Therefore, identifying clinical factors that could potentially influence functional recovery beyond the acute phase is essential to improve long-term outcomes for these patients.
Several studies and current clinical guidelines have highlighted the importance of a prompt intervention, comprehensive in-hospital care and early management of disease-associated disorders, such as cognitive impairment and depression, in improving the prognosis of patients with aSAH, reducing early complications and enhancing patient survival. Reference Zhao, Rabinstein, Murad, Lanzino, Panni and Brinjikji6–Reference Hoh, Ko and Amin-Hanjani11 However, the patient´s long-term recovery extends beyond initial hospitalization, and factors influencing outcomes in the post-discharge period, such as the role of discharge destination in functional recovery, remain underexplored.
Currently, although acute rehabilitation centers that specialize in the management of neurological patients are the gold standard of post-hospitalization care for patients with ruptured IAs, these are not sufficiently available in many developing and developed countries. The site of discharge post-aSAH may have a critical role in the trajectory of clinical recovery for patients with ruptured IAs. Acute rehabilitation centers provide multidisciplinary care, offering tailored physical, cognitive and occupational therapy, which may benefit patients with poor baseline neurological status. In this study, we aimed to evaluate the impact of discharge sites on long-term functional outcomes in patients with aSAH.
Methods
This study is a retrospective cohort analysis of patients with ruptured IAs. It was conducted in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Reference Von Elm, Altman, Egger, Pocock and Vandenbroucke12
Ethical considerations
This study was approved by the institutional Research Ethics Board. Given the retrospective design of this study, the requirement for written informed consent was waived. All data utilized in this study are available upon reasonable request to the corresponding author.
Study population and inclusion criteria
This study’s population focused on patients with aSAH managed within a tertiary neurovascular institution. At our institution, patients with ruptured IAs have been treated exclusively with an endovascular approach for the past years. Therefore, no patients treated with surgical clipping were available for inclusion. Inclusion criteria were as follows: a) patients aged 18 years or older, b) identified subarachnoid hemorrhage through initial computerized tomography, c) confirmed ruptured IA, identified through computerized tomography angiography, magnetic resonance angiography or diagnostic cerebral angiogram, d) treated with an endovascular approach and e) availability of comprehensive baseline, trans-hospitalization and long-term clinical data.
Exclusion criteria included: a) patients who died before hospital discharge, as long-term functional outcomes could not be assessed in this subgroup, b) subarachnoid hemorrhage without identifiable IA, c) other concomitant intracranial abnormalities which are not directly related to or caused by the identifiable IA (e.g. other cerebrovascular pathologies, intracranial tumors, etc.) and that could directly influence clinical course or recovery, d) presence of IA in the context of arteriovenous shunting and e) lack of available in-hospital clinical and imaging data. Patients without a minimum of 6-month post-hospitalization clinical follow-up were eliminated from this study.
Data collection and clinical scoring
Data from eligible patients treated between September 2019 and November 2024 were collected. Baseline clinical variables, as well as in-hospital clinical data, were documented. Clinical information from 6- and 12-month follow-ups was similarly collected.
The World Federation of Neurosurgical Societies (WFNS) grading scale score at admission and discharge modified Rankin Scale (mRS) scores were prospectively documented in the clinical chart by the treating team as part of standard institutional practice. Long-term follow-up mRS scores were obtained retrospectively through outpatient records and standardized follow-up visits.
Outcomes
The primary outcomes of interest were functional independence, defined as an mRS score of 0–2, as well as the overall change in mRS score at 6 and 12 months post-aneurysmal rupture. Patients were stratified based on their initial WFNS grading scale score to compare baseline characteristics and outcomes between those with good (WFNS 1–3) and poor (WFNS 4–5) initial scores.
Statistical analysis
For the descriptive statistics, qualitative variables were represented as frequencies and percentages, and quantitative variables as measures of central tendency (mean or median) and dispersion (standard deviation [SD] or interquartile range). One-way analysis of variance and Kruskal–Wallis test were used to compare more than two continuous, non-related, parametrically and non-parametrically distributed variables, respectively. Pearson’s χ2 was used to compare categorical, non-related variables. A paired-sample Student’s t-test was used to compare mRS scores as continuous related variables. Although mRS is an ordinal scale, mean and SD are reported to illustrate group-level trends of change in mRS, as represented in prior studies of functional recovery after aSAH. Median values are also provided, given the skewed distribution. A multivariate logistic regression model, adjusted for age, sex, baseline WFNS grading score and discharge mRS, was utilized to assess the odds of achieving functional independence at 6- and 12-month follow-ups. Statistical analyses were performed using IBM SPSS Statistics, version 25 (IBM Corp., Armonk, NY, USA). Statistical significance was set at a two-tailed p-value ≤ 0.05. Results are reported as p-values, 95% confidence intervals (CI) and adjusted odds ratios (aOR), where applicable.
Results
Baseline characteristics
Two hundred and thirteen patients with ruptured IAs were eligible and included in this study. In this cohort, a mean age of 55.9 ± 13.7 years was identified, and 164 (77%) were female patients. The most common risk factors identified within our sample were hypertension (123 patients; 57.7%), previous smoking (96 patients; 45.1%) and active smoking (80 patients; 37.6%).
In the overall cohort at hospital admission, the distribution of patients, according to the WFNS grading scale, was: 92 patients (43.2%) in grade 1, 46 patients (21.6%) in grade 2, 5 patients (2.3%) in grade 3, 40 patients (18.8%) in grade 4 and 30 patients (14.1%) in grade 5. The most prevalent modified Fisher Scale (mFS) score was 4 (103 patients; 48.4%).
The median hours from ictus to initial angiography, ictus to aneurysmal treatment and admission to aneurysmal treatment corresponded to 24 (18–33.5), 25 (18–42.5) and 15 (9–20), respectively. At hospital discharge, the most common mRS scores were 3 (57 patients; 26.8%), 1 (50 patients; 23.5%) and 4 (39 patients; 18.3%). The median number of days of in-trauma and neurosurgery intensive care unit (TNICU) and in-hospital stay was 12 (9–17) and 16 (12–23), respectively.
Comparative analysis of baseline characteristics between selected sites of discharge
Following hospitalization, discharge destinations included home (103 patients; 48.4%), primary care hospitals (57 patients; 26.8%) and acute rehabilitation centers (53 patients; 24.9%). Patients discharged to a primary care hospital were significantly older (62.3 ± 13.9 years; p < 0.001), had a higher proportion of female patients (89.5%; p = 0.013) and individuals with diabetes (15.8%; p = 0.011). This subgroup also showed a greater prevalence of high mFS grades (p < 0.001) and poor baseline WFNS grades at hospital admission (66.7%; p < 0.001).
Patients discharged home after aSAH exhibited higher rates of low mFS grades (p = < 0.001). Additionally, in the mRS score at hospital discharge, patients discharged home also demonstrated lower scores in comparison to other subgroups (p = < 0.001). No significant differences were identified in time to angiography or treatment between subgroups. In TNICU and hospital stay, patients discharged to another hospital demonstrated significantly longer stays in comparison to the other subgroups (p = < 0.001 in both). The detailed baseline clinical characteristics and comparative analyses by discharge destination are represented in Table 1.
Table 1. Baseline clinical characteristics of the overall cohort and by discharge destination in patients with ruptured intracranial aneurysms
Data are presented in median (interquartile range) and n (%) unless specified. SD = standard deviation; IQR = interquartile range; WFNS = World Federation of Neurosurgical Societies; mFS = modified Fisher Scale; mRS = modified Rankin Scale; TNICU = trauma and neurosurgery intensive care unit; Poor baseline WFNS grading scale: 4–5.
Overall change in modified Rankin Scale across discharge sites
Patients discharged to acute rehabilitation centers exhibited a greater reduction in mRS scores at 6- and 12-month follow-ups than those discharged elsewhere, particularly among patients with poor baseline WFNS grades. While patients discharged home demonstrated lower mean mRS scores overall, those with poor baseline WFNS grades had better 12-month mRS outcomes when discharged to an acute rehabilitation center compared to home (0.67 ± 0.59 vs. 1.18 ± 1.25; p = 0.396) or to discharge into a primary care hospital (0.67 ± 0.59 vs. 2.7 ± 1.32; p < 0.001). The measurements of central tendency and dispersion of the mRS scores, as well as the overall changes at 6- and 12-month follow-ups stratified by discharge site, are detailed in Table 2.
Table 2. Longitudinal changes in modified Rankin Scale scores at 6 and 12 months, stratified by discharge destination
Δ, Difference; WFNS = World Federation of Neurosurgical Societies; mRS = modified Rankin Scale; Good baseline WFNS grading scale: 1–3; Poor baseline WFNS grading scale: 4–5.
Effect of discharge site on long-term functional independence
Our multivariate logistic regression analysis in the overall cohort revealed that discharge to an acute rehabilitation center significantly increased the odds of achieving functional independence at 6 months (aOR 10, 95% CI 2.71–36.83, p = 0.001), although not maintained at 12-month follow-up. Conversely, patients discharged to a primary care hospital had lower odds of long-term functional independence at 6- (aOR 0.08, 95% CI 0.03–0.25, p < 0.001) and 12-month (aOR 0.2, 95% CI 0.08–0.5, p = 0.001) follow-up. Patients discharged home also showed higher odds of functional independence at the 12-month follow-up (aOR 5.17, 95% CI 1.44–18.55, p = 0.012).
These trends were maintained and strengthened in patients with poor baseline WFNS scores, both for those discharged to an acute rehabilitation center and to a primary care hospital. In patients with good baseline WFNS grading scale scores, lower odds of functional independence at 6-months were identified in patients discharged to another primary care hospital (aOR 0.14, 95% CI 0.03–0.7, p = 0.017), and higher odds at 12 months in patients discharged home (aOR 8.03, 95% CI 1.71–37.6, p = 0.008). The complete regression model demonstrating the odds of achieving functional independence for each discharge site is shown in Table 3.
Table 3. Multivariable logistic regression analysis assessing discharge destination as an independent predictor of functional independence (mRS 0–2) at 6- and 12-month follow-up
aOR = adjusted Odds Ratio; 95% CI, 95% confidence interval; WFNS = World Federation of Neurosurgical Societies; mRS = modified Rankin Scale; Good baseline WFNS grading scale: 1–3; Poor baseline WFNS grading scale: 4–5.
Discussion
In this study, we found an association between discharge to an acute rehabilitation center and improved long-term functional outcomes following aSAH, particularly among patients with poor baseline WFNS scores. In contrast, discharge to a primary care hospital was linked to significantly lower odds of achieving functional independence. These findings highlight the pivotal role of a structured post-acute rehabilitation in optimizing recovery trajectories after IA rupture.
As early mortality following aSAH continues to decline, the persistent neurological and functional impairments among survivors have become a growing focus of clinical research. Reference Etminan, Chang and Hackenberg13,Reference Neifert, Chapman and Martini14 Several studies have explored the effect of specific factors, such as early inpatient rehabilitation and neurostimulants, to identify those that might enhance functional outcomes. Reference Sundseth, Thommessen and Rønning15–Reference Gagnon, Leclerc and Riker17 However, the lack of studies examining the impact of discharge destination on long-term functional outcomes for patients with aSAH limits our understanding of post-hospitalization factors influencing clinical recovery.
Although the pathophysiological mechanisms of aSAH differ from those of ischemic stroke, both conditions often lead to lasting neurological deficits that impair independence and quality of life. Ischemic stroke research has consistently highlighted the importance of discharge to acute care centers in achieving better functional outcomes. Reference Lee, Choi and Jeoung18,Reference Coleman, Moudgal and Lang19 These improved outcomes are attributed to intensive, multidisciplinary care that addresses both physical and cognitive deficits. Reference Wang, Camicia, Terdiman, Hung and Sandel20,Reference Winstein, Stein and Arena21 Our findings suggest that similar principles are relevant for aSAH survivors, especially those with severe initial neurological impairment.
Personalized rehabilitation strategies that address the physical, cognitive and neuropsychological needs of patients following aSAH are essential to support the complexity of clinical recovery. Reference Nwafor, Kirby, Ralston, Colantonio, Ibekwe and Lucke-Wold22,Reference Chen, Wu and Li23 As our study indicates, constant exposure to specialized rehabilitation personnel may be particularly beneficial for patients with severe baseline neurological deficits. In contrast, discharge to other hospital facilities or home may result in fragmented rehabilitation or inadequate care, which could lead to poorer long-term outcomes.
Several retrospective studies have demonstrated the feasibility and safety of early in-hospital rehabilitation after aneurysmal obliteration in patients with ruptured IAs. Reference Karic, Røe, Nordenmark, Becker, Sorteberg and Sorteberg24–Reference Okamura, Konishi, Sagara, Shimizu and Nakamura26 A study by Alaraj et al. Reference Alaraj, Hussein, Esfahani, Amin-Hanjani, Aletich and Charbel27 showed that a multidisciplinary team approach to identify discharge needs significantly reduced the length of stay for patients with aSAH. However, our findings suggest that this specialized rehabilitation should extend beyond the immediate in-hospitalization phase. Ensuring continuous, specialized care for patients with ruptured IAs post-discharge may be crucial for enhancing long-term functional outcomes.
In our cohort, discharge home appeared to be often prioritized for patients without relevant clinical deficits. In this subgroup of patients, discharge to an acute rehabilitation facility or into another hospital facility does not appear to influence the odds of achieving functional independence. However, for patients with significant clinical deficits at baseline, our data suggest that referral to a primary care hospital should be avoided when feasible and secure, while promoting early exposure to rehabilitation services to improve functional independence. The trend of increased discharge to inpatient rehabilitation facilities for stroke patients in recent years, as noted by Venkatachalam et al. Reference Venkatachalam, Rabroker, Stone, Manchi, Sengupta and Ifejika28 , highlights the growing recognition of the benefits of specialized rehabilitation. Early exposure to rehabilitation services, in addition to customization of the discharge site with each patient’s specific needs, could optimize clinical recovery and reduce long-term disability in patients with ruptured IAs, as shown in stroke research. Reference Gladman, Lincoln and Barer29,Reference Maulden, Gassaway, Horn, Smout and DeJong30
The Canadian healthcare context lends additional weight to these findings. Access to inpatient neurorehabilitation services varies significantly across provinces, with patients in rural or smaller urban centers often facing limited availability or delays in specialized post-acute care. Reference Allen, Richardson and McIntyre31 Moreover, sex-based disparities in the provision of neurorehabilitation have also been documented in Ontario, where women were found to receive significantly less intensive rehabilitation than men. Reference MacDonald, Linkewich and Bayley32 In this context, ensuring timely and equitable access to structured rehabilitation services is not only essential for optimizing functional recovery but also for addressing broader issues of health system equity and consistency in post-acute neurovascular care. Similar to the well-established standardized care pathways for ischemic stroke, the development of structured discharge and rehabilitation protocols for patients with aSAH may help reduce regional variability and improve long-term outcomes.
Incorporating a multidisciplinary approach that includes neurosurgeons, neurocritical care specialists, psychiatrists and rehabilitation specialists should be encouraged when determining discharge plans for patients with ruptured IAs. Furthermore, given the significant improvements in functional independence observed in our study, guidelines for the management of patients with aSAH should advocate for immediate discharge to acute rehabilitation centers when secure, especially in the context of severe initial neurological impairment. Promotion of early and continuous inpatient rehabilitation after hospital discharge could aid in reducing long-term disability and improving the quality of life for survivors of ruptured IAs. Future larger and prospective studies are needed to further explore this relationship, including evaluations of current Canadian practices and organizational structures, to promote a shift toward prioritizing early specialized rehabilitation as a standard of post-hospitalization care.
Limitations
Although this study offers valuable insights into the impact of discharge destination on long-term functional recovery in patients with ruptured IAs, several limitations must be acknowledged. First, the retrospective design inherently introduces the possibility of selection and information biases, which may affect the accuracy and interpretability of our findings. As this was an observational study, the association between discharge site and outcome cannot be interpreted as causal, and residual confounding may persist despite statistical adjustment.
A key limitation involves the potential for confounding in discharge allocation. Patients with better functional capacity at hospital discharge were more frequently transitioned to acute rehabilitation centers or discharged home, whereas those with more severe deficits were often transferred to primary care hospitals. Allocation decisions were based on multidisciplinary clinical judgment rather than standardized assessment tools, which may partly explain why discharge mRS alone did not determine eligibility for rehabilitation. To mitigate this bias, we conducted multivariate logistic regression analyses stratified by baseline WFNS grade, which demonstrated consistent trends across both good- and poor-grade subgroups. Nonetheless, residual confounding may persist.
In addition, it remains unclear whether patients transferred to other hospitals were subsequently reassessed for rehabilitation eligibility or whether transfer reflected temporary convalescence versus a more permanent transition to long-term care. The inability to distinguish these subgroups represents another potential confounder, underscoring the need for prospective, controlled studies explicitly evaluating discharge destination as an independent determinant of functional outcome after aSAH. Furthermore, information on patients’ living situations at 6 and 12 months (e.g., return to independent living vs. institutionalization) was not consistently available and could not be analyzed. This represents an important outcome measure that should be incorporated into future studies, as it may provide additional insight into the broader impact of discharge site on recovery and quality of life.
Finally, this study was conducted at a single high-volume neurovascular center, which may limit the generalizability of our findings to other institutions with different patient populations, treatment protocols and discharge practices. Notably, all patients in this cohort were treated with endovascular techniques, reflecting the standard of care at our center over the past several years. As surgical clipping is not routinely performed at our institution, the applicability of these findings to surgically managed aSAH populations may be limited. Larger, multicenter prospective studies are warranted to validate these findings across diverse clinical settings.
Conclusions
Extending in-hospital stay by discharge to a primary care hospital following aSAH was associated with significantly lower odds of achieving long-term functional independence. In contrast, early transfer to an acute rehabilitation center was linked to improved outcomes, particularly among patients with poor baseline WFNS grades. These findings highlight the critical importance of early and specialized post-acute rehabilitation in optimizing recovery after aneurysmal rupture. Prioritizing structured rehabilitation pathways and minimizing prolonged hospital stays without access to specialized rehabilitative care may substantially enhance functional recovery and long-term quality of life in this population.
Author contributions
DAOM: Conceptualization, Methodology, Formal analysis, Investigation, Data Curation, Writing – Original Draft, Writing – Review & Editing. IA: Conceptualization, Validation, Investigation, Writing – Review & Editing. JCK: Conceptualization, Validation, Investigation, Writing – Review & Editing. NC: Conceptualization, Methodology, Resources, Writing – Review & Editing, Supervision, Project administration. DBD: Validation, Resources, Writing – Review & Editing, Supervision. TRM: Validation, Resources, Writing – Review & Editing, Supervision. JS: Validation, Resources, Writing – Review & Editing, Supervision. AAD: Methodology, Validation, Formal analysis, Data Curation, Writing – Review & Editing. VMP: Conceptualization, Validation, Investigation, Resources, Writing – Review & Editing, Supervision.
Funding statement
None.
Competing interests
No conflicts of interest to disclose.
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