Neurosurgical Review · Oct 28, 2026

When age matters: mortality and disability after aneurysmal subarachnoid hemorrhage in a cohort of elderly patients

By Fiore G, Reischer G, Kovacs B et al.

Aneurysmal subarachnoid hemorrhage (aSAH) in older adults is associated with high early mortality and substantial long-term disability. As referral patterns and neurocritical care have evolved, the age at which prognosis changes markedly remains uncertain, and longitudinal functional trajectories beyond discharge are poorly characterised in elderly patients. We retrospectively included consecutive patients aged 65 years or older admitted with confirmed aSAH to the National Hospital for Neurology and Neurosurgery (London, UK) between February 2013 and August 2022. Primary outcomes were in-hospital mortality, all-cause mortality during follow-up, and functional disability (modified Rankin Scale, mRS) at discharge and last follow-up (unfavourable outcome defined as mRS 4-6). Age thresholds associated with mortality and disability were identified using receiver operating characteristic analysis with the Youden index and confirmed by maximally selected rank statistics. Predictors of in-hospital death, survival, and disability were evaluated using multivariable logistic regression and Cox proportional hazards models. Functional trajectories were summarised using transition matrices and Sankey diagrams. Among 110 patients (median age 76 years; 80% women), in-hospital mortality was 18.2% and all-cause mortality during follow-up was 48.2% (median follow-up 24 months). Age independently predicted in-hospital death (odds ratio 1.19 per year, 95% CI 1.06-1.35) and long-term mortality (hazard ratio 1.16 per year, 95% CI 1.09-1.22). An exploratory, cohort-derived age cut point of 79.5 years delineated divergent trajectories: mortality increased from 10.4% in patients aged < 80 years to 36.4% in those aged ≥ 80 years, and median survival declined from 95 months to 3 months (log-rank p = 2.8 × 10⁻⁶). Among patients discharged alive, discharge mRS independently predicted post-discharge survival (hazard ratio 2.39 per point, 95% CI 1.60-3.56), including in those aged ≥ 80 years (hazard ratio 3.34, 95% CI 1.21-9.20). Functional trajectories showed frequent post-discharge recovery in patients aged < 80 years, whereas recovery was uncommon and progression to death frequent in those aged ≥ 80 years. In this cohort of elderly patients with aSAH, an exploratory, cohort-derived threshold of approximately 80 years identified patients with markedly lower survival and functional recovery. Longitudinal trajectory analysis suggests post-discharge improvement remains common in patients aged < 80 years but rare in those aged ≥ 80 years.

doi.org/10.1007/s10143-026-04546-wPubMed 42946922Populations