Treatment times for rural and urban patients with aneurysmal subarachnoid hemorrhage in a provincial hub-and-spoke network

BACKGROUND: Following aneurysmal subarachnoid hemorrhage (aSAH), aneurysm rebleeding leads to very poor clinical outcomes. Ruptured aneurysms must be urgently secured either by open microsurgery or endovascular techniques to prevent re-rupture. The objective of this study was to compare time-to-treatment and functional outcomes following aSAH between rural and urban patients treated at a quaternary neurosurgical centre with a large geographical catchment. METHODS: We analyzed patients enrolled in the Vancouver Ruptured Aneurysm Database (VRAD) between December 2022 and September 2025. Demographic, clinical, radiographic, treatment and functional outcomes were compared between groups. Time from ictus-to-presentation, ictus-to-neurosurgical centre, ictus-to-treatment and transfer times were collected. Proportion of aneurysms treated within 24 hours of ictus were also compared between groups. RESULTS: Our cohort included 124 patients: 81 (65.3%) urban and 43 (34.7%) rural. Rural patients lived farther from the neurosurgical centre (>100 km: 79.1% vs. 9.9%; >500 km: 30.2% vs. 0%). Rural patients had longer transfer times from outside hospital to neurosurgical centre (median 11.5 vs. 5.0 h; p < 0.001) and longer time from ictus-to-neurosurgical centre (median 13.2 vs. 5.5 h; p < 0.001). Despite rural patients having longer times from ictus-to-treatment (median 24.0 vs. 22.2 h; p < 0.001), there were no differences in proportion of patients treated within 24 h of ictus (rural 51.2% vs urban 54.3%; p = 0.737). Discharge disposition, mortality (12.1%), and mRS at discharge (mean 3.2 ± 1.9) and 3 months (mean 3.1 ± 2.4) were comparable between groups. However, rural patients reported lower 3-month post-aSAH quality of life than urban patients (mean EQ-5D: 71.4 vs. 80.3; p = 0.042). CONCLUSIONS: Rural patients with aSAH achieve comparable time-to-treatment, likelihood of being treated within 24 hours of ictus and functional outcomes, to urban patients when treated at a high-volume neurosurgical centre with a robust centralized system of inter-hospital neurosurgery consultation and transfer. Rural patients, however, experience a significantly worse quality-of-life 3 months following aneurysm treatment. Over a large geographical area, timely access to comprehensive aSAH management and treatment is possible for rural patients in a system where care delivery and transfer is coordinated and centralized. Coordinated regional hospitals and transfer protocols are essential to enable timely and equitable aSAH care.