Long-Term Clinical Trajectory of Patients with Subarachnoid Hemorrhage: Linking Acute Care and Neurorehabilitation

Abstract

Background: Despite improvements in the critical care management of subarachnoid hemorrhage (SAH), a substantial number of patients still suffer from disabilities. In most areas of the world, longitudinal follow-up is not routinely performed, and the patient's trajectory remains unknown.

Methods: We prospectively collected data of 298 consecutive patients with spontaneous SAH and evaluated clinical trajectories at discharge, 3 months, and 1 year after SAH. In a subgroup of patients transferred to a local neurorehabilitation center (Rehab-Hochzirl), we studied the effects of rehabilitation intensity on clinical trajectories. Any decrease in the modified Rankin Scale (mRS) was defined as an improvement, with mRS ≤ 2 indicating good outcome. We used multivariate generalized linear models to investigate associations with clinical trajectories.

Results: Out of the 250 surviving patients, 35% were transferred directly to Rehab-Hochzirl (n = 87 of 250; mRS at discharge = 4), 11% were transferred to another rehabilitation center (n = 27 of 250; mRS = 1), 1% were transferred to a nursing home (n = 3 of 250; mRS = 5), 21% were transferred to their country of origin (n = 52 of 250; mRS = 4), and 32% (n = 79 of 250; mRS = 1) were discharged home. Functional outcome improved in 57% (n = 122 of 215) of patients during the first 3 months, with an additional 16% (35 of 215) improving between 3 and 12 months, resulting in an overall improvement in 73% (n = 157 of 215) of survivors. After 1 year, 60% (n = 179 of 250) of patients were functionally independent. A lower Hunt and Hess scale score at intensive care unit admission, younger age, a lower mRS at intensive care unit discharge, fewer days on mechanical ventilation, and male sex were independently associated with better functional recovery. Although the subgroup of patients transferred to Rehab-Hochzirl were more severely affected, 60% (52 of 87) improved during inpatient neurorehabilitation.

Conclusions: Our results indicate ongoing functional improvement in a substantial number of patients with SAH throughout a follow-up period of 12 months. This effect was also observed in patients with severe disability receiving inpatient neurorehabilitation.

Keywords: Critical care; Neurorehabilitation; Subarachnoid hemorrhage.

Fig. 1

Patient selection. Flowchart showing the selection of eligible patients and the different analysis groups. ICU intensive care unit, mRS modified Rankin Scale, SAH subarachnoid hemorrhage

Fig. 2

Distribution of ICU discharges. H&H Hunt and Hess scale, ICU intensive care unit

Fig. 3

Count of patients per mRS category at ICU discharge, 3 months, and 12 months after SAH in 298 patients with SAH. The number of patients in each mRS category increased steadily from the time of acquisition through the time of discharge. ICU intensive care unit, mRS modified Rankin Scale, SAH subarachnoid hemorrhage

Fig. 4

Subgroup analysis: count of patients per mRS category at ICU discharge, 3 months, and 12 months after subarachnoid hemorrhage in 87 Rehab-Hochzirl patients. The number of patients in each mRS category increased steadily from the time of acquisition through the time of discharge. ICU intensive care unit, mRS modified Rankin Scale