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Background Aneurysmal subarachnoid hemorrhage (aSAH) carries substantial morbidity including cognitive impairment, with survivors frequently experiencing deficits in attention, memory, language, and executive function. Temporal trends in outcomes and the impact of age and concomitant intracerebral/intraventricular hemorrhage (ICH/IVH) on recovery trajectories remain incompletely characterized. We aimed to evaluate temporal trends in mortality and cognitive outcomes following aSAH, stratified by time period, age, and ICH/IVH presence.Methods We conducted a retrospective cohort study using the TriNetX federated database (January 2016 to December 2025). Patients with aSAH were identified and stratified into early (2016-2019) and recent (2020-2025) eras. Two parallel propensity score-matched analyses were performed to compare time periods and age groups (18-40 vs 41-80 years). Matching balanced demographics, comorbidities, medications, vital signs, and clinical indications (SMD less than 0.1). Patients with pre-existing dementia or psychosis were excluded. The primary outcome was all-cause mortality at 1-year and 3-year follow-up. Secondary outcomes included overall cognitive impairment (composite), domain-specific deficits (attention, memory, language, executive function), mood changes/anxiety, and fatigue. A separate analysis compared aSAH patients with versus without concomitant ICH/IVH. Vasospasm (within 30 days) and delayed cerebral ischemia (DCI, 4-30 days) were assessed as potential mediators.Results Approximately 5,600-1,200 propensity score-matched patients were analyzed per comparison. For temporal trends, mortality increased from the early to recent era: 1-year mortality rose from 18.2% to 21.1% (change +2.9%; HR 0.85, p=0.0001), and 3-year mortality rose from 20.0% to 22.5% (change +2.5%; HR 0.85, p=0.0001). Vasospasm rates remained stable (33.6% vs 32.6%), as did DCI (5.6% vs 5.9%). Overall cognitive impairment modestly improved: 1-year rates decreased from 54.0% to 52.8% (HR 1.01, p=0.16), and 3-year rates decreased from 56.6% to 54.9% (HR 1.01, NS). Domain-specific analysis revealed divergent trajectories: attention deficits improved (9.1% to 8.4% at 3 years; HR 1.08), memory remained stable (14.5% to 14.8%), while language deficits worsened (21.4% to 23.2% at 3 years; HR 0.91, p=0.02) as did fatigue (13.1% to 13.6%; HR 0.89, p=0.03). For age stratification, older patients (41-80 years) had significantly higher mortality at both 1-year (15.3% vs 14.2%; HR 0.67, p<0.0001) and 3-year (21.7% vs 20.6%; HR 0.68, p<0.0001) follow-up. However, cognitive impairment rates did not differ significantly by age (46.5% vs 49.0% at 1 year; 48.0% vs 50.5% at 3 years; HR 0.95, NS). Patients with concomitant ICH/IVH (N=10,586 matched) had dramatically worse outcomes: mortality 27.4% vs 13.9% at 1 year (HR 2.15) and 28.9% vs 15.4% at 3 years (HR 2.06); cognitive impairment 62.7% vs 49.8% at 1 year (HR 1.43) and 64.3% vs 52.6% at 3 years (HR 1.42). The ICH/IVH group also had higher vasospasm (40.1% vs 28.2%, p<0.0001) and DCI rates (8.4% vs 3.7%, p<0.0001).Conclusion Despite modest improvements in cognitive outcomes, aSAH mortality increased in the recent era, potentially reflecting COVID-19 era effects. Age predicted functional but not cognitive outcomes, while concomitant ICH/IVH strongly predicted worse mortality and cognition. Language deficits and fatigue represent key unmet therapeutic needs.Disclosures M. Essibayi: None.