Pre-existing Neurological Disease Research Articles

Anaesthetic implications of neurological disease in pregnancy

The advances in medicine mean that more women with pre-existing neurological disease, who previously may not have lived to childbearing age, are choosing to become pregnant despite the risks. Other women may coincidentally exhibit their first symptoms during pregnancy. When caring for these patients, it is important to have a comprehensive understanding of the underlying pathophysiology and recognize the potential for exacerbation during pregnancy. Neurological disease remains a significant cause of maternal morbidity and mortality with eight direct and 37 indirect deaths attributed to central nervous system (CNS) disorders in the 2003–5 CEMACH report (Table 1).

Neurologic Issues and Obstetric Anesthesia

The rising popularity of regional anesthesia in the last several decades has greatly changed the experience of labor. Although the use of regional anesthesia has aided in decreasing maternal morbidity and mortality, a new dimension of neurologic issues, particularly headache and peripheral neuropathy, is apparent. Obstetric anesthesiologists frequently encounter patients with preexisting neurologic disease. Although very few of these disorders contraindicate the use of neuraxial technique, there are limited published data on specific neurologic and neuromuscular disorders in pregnancy. Neurologists are often consulted by anesthesiologists and obstetricians to evaluate pregnant patients for the feasibility of labor analgesia and when postpartum neurologic complications arise. Early consultation with an obstetric anesthesiologist, discussion with a neurologist, and communication with the obstetrician allows for the education and discussion of the risks and benefits of both the mode of delivery and anesthetic options. This multidisciplinary approach is crucial in forming reasonable expectations for the patient. The aim of this discussion is to provide an obstetric anesthesiologist's perspective on regional anesthesia and its implications in obstetrics, and to enhance communication between our specialties.

Pandemic influenza A (H1N1v) infection in pediatric population: a multicenter study in a North-East area of Italy

Background -Data on clinical presentation, morbidity and mortality of 2009 pandemic influenza virus (H1N1v) in paediatric population are still emerging; most of the data so far available came from selected cohorts of children admitted to tertiary care paediatric hospitals.Methods -An observational study involving all the 19 Divisions of Paediatrics of the Veneto Region was conducted with the aim of investigating into the demographic and clinical characteristics, the treatment, the outcome and the risk factors for disease severity of H1N1v infection occurring in children.Results -Two hundred children, median age of 4.15 years (range 0-15) were enrolled from the last week of October till the first week of January 2010 for an overall hospitalization rate of 23/100.000. At least one underlying medical condition was found in 44% of patients. Fever and cough were the most frequent symptoms (93% and 65% respectively). 11 patients (6%) were admitted to a PICU and 5 (2.5%) required mechanical ventilation. Antiviral therapy was administered in 103 patients (51.5%) Death occurred in 2 patients (1%); both had severe prior medical conditions. Pre-existing neurologic diseases (OR 7.82; 95%CI: 1.15-53.34), the presence of hypoxemia (OR 10.47; 95%CI: 2.12-51.70) and anemia (Haemoglobin < 10 g/dL) (OR 14.15; 95%CI: 2.36-84.64) were risk factor for Intensive Care Unit admission.Conclusions -This observational study in a given area of North-East Italy confirms the rather favourable prognosis of children with influenza A H1N1 (2009). Pre-existing conditions, and which is new, significant anemia, are risk factors for a complicated course.

Regional anesthesia and the patient with preexisting neurological disease

Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands Correspondence to Bernadette T. Veering, MD, PhD, Department of Anesthesiology, Leiden University Medical Center, P5-Q, P.O. Box 9600, 2300 RC Leiden, The Netherlands Tel: +31 71 5262302; fax: +31 71 5266230; e-mail: [email protected]

Experience of Epidural Steroids in Transverse Myelitis -A case report-

Transverse myelitis is a focal inflammatory disorder of the spinal cord characterized by motor, sensory, and autonomic dysfunction. A 41-year-old man with transverse myelitis and no pre-existing neurologic disease presented with hypesthesia, numbness, weakness in the both lower extremities, back pain, decreased libido, constipation, and dysuria. A MRI test showed intramedullary high signal intensity between T4 and T8 on a T2-weighted image. After high-dose intravenous methylprednisolone and oral prednisolone therapy, he showed facial swelling and acneiform eruption. Therefore, we injected 40 mg methylprednisolone via an epidural route. A 7-dose serial treatment improved most symptoms. A follow up MRI showed radiological improvement. We report a case of transverse myelitis treated by epidural steroids.

Regional anesthesia and pre-existing neurological disease —I

To the Editor: Dhir et aL ~ should be congratulated for successfully administering regional anesthesia to a small series of patients with Charcot-Marie-Tooth disease. In reading the aforementioned case reports, it not only becomes apparent that dissimilar approaches to the brachial plexus were utilized but also that different local anesthetic solutions and volumes were employed. 1 Universally absent from these local anesthetic solutions was epinephrine. 1 Epinephrine possesses a complex pharmacodynamic profile and exerts dose dependent changes in peripheral nerve blood flow. 2 For example, a 1:200,000 concentration of epinephrine has been demonstrated to decrease peripheral nerve blood flow. 2 Unsurprisingly, this reduction in regional blood flow is well tolerated in patients without vascular compromise or peripheral nervous system disorders. 2 However, patients afflicted with peripheral nervous system disorders, including Charcot-Marie-To oth disease, may be more susceptible to nerve damage following periods of diminished blood supply. Maintaining blood flow to a partially demyelinated nerve may eliminate one etiology involved in the double-crush phenomenon) Remote from these vascular properties, epinephrine may also enhance local anesthetic induced nerve toxicity. 2 Given the possible injurious consequences of epinephrine, the authors x should be applauded for omitting this vasoconstrictor from their local anesthetic solutions. Given the equivocal patient responses to nerve stimulation, ultrasound guidance allowed these practitioners to strategically place local anesthetic circumferentially around the brachial plexus) The authors do not mention in their article whether the epineurium was violated or if the local anesthetic was placed outside the epineural barrier and allowed to diffuse inward.1 When placed underneath the epineurium, local anesthetics may diminish peripheral nerve blood supply secondary to edema or a mass effect. 4 By not breeching the epineurim and allowing the local anesthetic solution to diffuse inward, it is possible that nerve fascicles in the endoneurium are exposed to a lower concentration of local anesthetic. In general, higher concentrations of local anesthetics produce increased cytotoxic effects. 5 These cytotoxic effects are typically proportionate to duration of exposure to local anesthetic, s It is worth mentioning that Dhir et al. 1 did not incorporate bupivacaine into any of their local anesthetic solutions.

Regional anesthesia and pre-existing neurological disease — II

To the Editor: Dhir et aL ~ should be congratulated for successfully administering regional anesthesia to a small series of patients with Charcot-Marie-Tooth disease. In reading the aforementioned case reports, it not only becomes apparent that dissimilar approaches to the brachial plexus were utilized but also that different local anesthetic solutions and volumes were employed. 1 Universally absent from these local anesthetic solutions was epinephrine. 1 Epinephrine possesses a complex pharmacodynamic profile and exerts dose dependent changes in peripheral nerve blood flow. 2 For example, a 1:200,000 concentration of epinephrine has been demonstrated to decrease peripheral nerve blood flow. 2 Unsurprisingly, this reduction in regional blood flow is well tolerated in patients without vascular compromise or peripheral nervous system disorders. 2 However, patients afflicted with peripheral nervous system disorders, including Charcot-Marie-To oth disease, may be more susceptible to nerve damage following periods of diminished blood supply. Maintaining blood flow to a partially demyelinated nerve may eliminate one etiology involved in the "double-crush phenomenon") Remote from these vascular properties, epinephrine may also enhance local anesthetic induced nerve toxicity. 2 Given the possible injurious consequences of epinephrine, the authors x should be applauded for omitting this vasoconstrictor from their local anesthetic solutions. Given the equivocal patient responses to nerve stimulation, ultrasound guidance allowed these practitioners to strategically place local anesthetic circumferentially around the brachial plexus) The authors do not mention in their article whether the epineurium was violated or if the local anesthetic was placed outside the epineural barrier and allowed to diffuse inward.1 When placed underneath the epineurium, local anesthetics may diminish peripheral nerve blood supply secondary to edema or a mass effect. 4 By not breeching the epineurim and allowing the local anesthetic solution to diffuse inward, it is possible that nerve fascicles in the endoneurium are exposed to a lower concentration of local anesthetic. In general, higher concentrations of local anesthetics produce increased cytotoxic effects. 5 These cytotoxic effects are typically proportionate to duration of exposure to local anesthetic, s It is worth mentioning that Dhir et al. 1 did not incorporate bupivacaine into any of their local anesthetic solutions.

Can Ultrasound Impact the Risk–Benefit Ratio for Nerve Blocks?

Wayne State University, Detroit, Michigan. rkbaumgarten@comcast.netTo the Editor:— Dr. Hebl’s editorial1is thought provoking. The real potential of ultrasound lies in the opportunity to approach nerve blocks in entirely new ways. Regional anesthesia for hand surgery provides an example. Many anesthesiologists consider it axiomatic that one should avoid performing nerve blocks close to the tourniquet. This is partially defensive because “when the site of the block is close to the tourniquet, electromyographic and conduction nerve studies cannot allow such differentiation and by default, the anesthesiologist is usually blamed.”2Despite this caveat, the most commonly used regional technique for hand surgery with an upper arm tourniquet is the axillary block. If one subscribes to the theory that serious nerve damage from axillary block is often the result of vascular trauma and a medial brachial fascial compartment syndrome,3rather than direct needle–nerve trauma, it is even more imperative to avoid axillary block with an upper arm tourniquet.Ultrasound should permit the near total abandonment of the axillary block. With ultrasound, peripheral nerve blocks in the mid forearm become straightforward.4,5These blocks should replace the axillary block for minor hand surgery (e.g. , carpal tunnel, digit fractures).6Before ultrasound, many anesthesiologists avoided supraclavicular and infraclavicular blocks for fear of pneumothorax. With ultrasound, the lung and major vessels are directly visualized, so the proceduralist avoids them as a matter of course. For major hand, wrist, and elbow surgery, ultrasound-guided supraclavicular or infraclavicular blocks should be the first choice whenever an upper arm tourniquet is used.The gist of Hebl’s editorial and Koff et al. ’s case report7seems to be that this patient had an unfavorable risk–benefit ratio due to preexisting neurologic disease. But, where was the benefit in the first place? For total shoulder replacement, the requirement for significant pain control will far outlast any single-shot nerve block. The “tip-of-the iceberg” reports of permanent diaphragmatic paralysis8after uneventful interscalene blocks offer another reason to demure the use of single-shot interscalene blocks for shoulder surgery. Ultrasound may allow more use of suprascapular blocks, either single shot or continuous.9The ultrasound-guided suprascapular block may not be quite as effective, but it avoids the interscalene’s dreaded complications. For major shoulder surgery without evidence of preexisting brachial plexopathy, continuous brachial plexus blocks are still encouraged. The risk of a continuous block can be justified to the patient because it provides prolonged analgesia matched to the requirements of major surgery.Ultrasound allows the abandonment of some, but not all, traditional practices associated with nerve blocks. Many ultrasonographers no longer aspirate before injection, because ultrasound is a far more sensitive detector of intravascular injection than any aspiration test. The same cannot be said for potential intrafascicular injection. As Dr. Hebl notes, the precise position of the tip and the nerve is not always apparent until one has injected 2–3 ml of local anesthetic. In the unlikely situation where one has actually placed the needle tip into a nerve fascicle, the damage may already be done before anything shows up on ultrasound. Therefore, ultrasound may not obviate the need for injection pressure monitoring during nerve blocks. Injection pressure can be monitored with an inexpensive proprietary device (BSmart; Concert Medical, Norwell, MA) or by assessing the compression of an air bubble above the local anesthetic in the syringe.10Only when we thoroughly rethink our approach to surgical nerve blocks will ultrasound fulfill its potential for improved safety.Wayne State University, Detroit, Michigan. rkbaumgarten@comcast.net

Neurological disease in pregnancy

Neurological disease presents a particular challenge to those providing obstetric care, to minimise maternal, foetal and neonatal morbidity. Women with pre-existing neurological disease should ideally be given a preconceptual assessment in order to optimise medical management. Headache is an extremely common problem both during and outside of pregnancy and requires a structured approach. Some conditions, such as eclampsia, are unique to pregnancy, whereas others, such as carpal tunnel syndrome, are seen much more frequently but not exclusively in pregnancy. The drug management of epilepsy in pregnancy represents a particular challenge, balancing the desire to limit foetal exposure on the one hand, with the need to maintain therapeutic benefit to the mother on the other. Assessment of all neurological conditions requires a sound knowledge of neuroanatomy and the physiology of pregnancy, with appropriate use of neuroimaging and neurophysiological testing. Management should involve a multidisciplinary team with specialist neurological input.

RS 3PE Presenting in a Unilateral Pattern: Case Report and Review of the Literature

To review the clinical features and pathophysiologic implications of remitting seronegative symmetrical synovitis with pitting edema (RS(3)PE) presenting in a unilateral manner. We identified and characterized an index case of RS(3)PE presenting in a unilateral pattern. We subsequently performed a systematic literature search to identify other reports of patients with unilateral RS(3)PE. The index case was a 76-year-old male with a prior history of right hemiparesis owing to a cerebrovascular accident 25 years prior, who developed a classic picture of RS(3)PE involving hand (metacarpophalageal and wrist joint) arthritis and dorsal pitting edema, accompanied by an elevated erythrocyte sedimentation rate, but only in the nonhemiparetic hand. The condition responded rapidly to low-dose prednisone. Our literature search identified 5 other cases of unilateral RS(3)PE, including 2 presented only in the Italian or German literature. Of the 5 cases, 2 were in patients with preexisting neurologic disease, in which the neurologically affected side was spared. One additional case initially presented as unilateral disease but rapidly progressed to bilaterality. Two cases presented in a fully unilateral manner despite no reported neurologic abnormalities on the unaffected sides. While RS(3)PE is almost always a symmetric disease of the upper extremities, it may rarely present in a unilateral fashion. The apparent ability of neuropathic changes to protect against the expression of RS(3)PE in an extremity suggests a role for neural and possibly other local factors in the genesis/modulation of the onset or maintenance of RS(3)PE.

Schwere Lithiumintoxikationen bei normalen Serumspiegeln

Lithium is known to be neurotoxic at higher serum levels. In rare cases patients develop symptoms of intoxication or full blown intoxications even when lithium levels are normal. Our aim was to detect predicting factors of lithium neurotoxicity at normal serum lithium levels in order to allow prevention of those constellations. We report two cases of severe lithium intoxications at normal serum lithium levels and review the current literature concerning lithium neurotoxicity at normal serum levels. It appears that the probability of developing signs of lithium intoxications in patients treated with lithium is increased with advanced age, co-morbidity with pre-existing neurological or other general diseases, especially those associated with fever, and in combination with the use of antipsychotics, antidepressants or mood stabilizers. The serum lithium level does not necessarily detect an intoxication. In patients developing signs of intoxication under lithium therapy, further investigations should include serum levels and an EEG. Because intoxications can occur even in normal serum levels, discontinuation of lithium medication should be taken into account on the basis of clinical signs of intoxication.

Physiological Adaptations of Pregnancy Affecting the Nervous System

Physiological adaptations of pregnancy affect neurological function in health and disease. Women often experience self-limited sensory abnormalities that resolve shortly after delivery. More important, pregnancy can predispose to the onset or deterioration of permanent neurological disorders. Lastly, complications of pregnancy may develop in patients with preexisting neurological disease. Therefore, a basic knowledge of reproductive physiology can guide clinicians in the diagnosis and management of the pregnant patient with neurological symptoms. This clinical review highlights the modifications that affect the nervous system, including neuroanatomy, reproductive endocrinology, immunology, systemic and cerebral circulations, metabolism, and coagulation profile. The widespread role of sex steroids in many of these adaptations is addressed to illustrate the complex interactions of human reproductive biology.

The New York School of Regional Anesthesia: Textbook of Regional Anesthesia and Acute Pain Management.

The New York School of Regional Anesthesia: Textbook of Regional Anesthesia and Acute Pain Management.

Anaesthetic considerations for patients with a pre‐existing neurological deficit: are neuraxial techniques safe?

Pre-existing neurological and muscular disease may be a specific concern for anaesthetists as they need to consider the effect of anaesthesia upon the disease, vice versa, and the interaction of anaesthesia with the medication taken by the patient. Despite a lack of controlled studies, many anaesthetists, being afraid of a claim, will prefer general rather than regional anaesthesia in these patients. Nevertheless regional anaesthesia certainly merits its place because it offers undeniable advantages. A good pre-operative examination is very important while patients should also be informed about peri-operative implications of anaesthesia, surgery and stress. Paraesthesias, epinephrine and high concentrations of local anaesthetics should be avoided in the majority of the diseases. Some diseases may benefit from epidural anaesthesia while for others a spinal technique may be the technique of preference. Special attention should be paid to patients with spinal stenosis despite recent reassuring reports with respect to safety of regional anaesthetic techniques. Anaesthetists should not automatically take all responsibility in case of progressive or new deficit after the procedure.

Neurotoxicity upon infusion of dimethylsulfoxide‐cryopreserved peripheral blood stem cells in patients with and without pre‐existing cerebral disease

Toxicity related to the infusion of dimethylsulfoxide (DMSO)-cryopreserved peripheral blood stem cells (DMSO-PBSC) mainly comprises cardiovascular events. Fatal neurotoxicity has been reported in a few cases. DMSO represents the putative causative agent of such rare toxicities and elaborate strategies to replace DMSO would benefit from the identification of predisposing factors for DMSO-related toxicities. Here, we report on DMSO-related neurotoxicity in a series of patients (n = 51) receiving DMSO-PBSC. The analyzed patient-series included eight patients with pre-existing cerebral disease, partially with a history of epileptic seizures. Neurotoxicity was observed in only one patient who suffered from a generalized tonic seizure upon infusion of DMSO-PBSC and for which the clinical course is reported herein. No neurotoxicity was observed in the group of patients with pre-existing neurological disease. Furthermore, no neurotoxicity was observed in patients who received particularly large volumes of DMSO. In all patients, mild non-neurological side effects occurred but besides the reported seizure no other severe adverse events were observed upon PBSC-infusion. To our knowledge, this is the first report addressing the identification of predisposing factors for DMSO-related neurotoxicty. We conclude that infusion of DMSO-PBSC can be performed safely in patients with pre-existing cerebral disease despite the rare occurrence of severe neurotoxicity. Retrospective multicenter studies are warranted to identify patients who would benefit from elaborate methods of DMSO-replacement.

Neuraxial Anesthesia and Analgesia in Patients with Preexisting Central Nervous System Disorders

Historically, the use of regional anesthetic techniques in patients with preexisting central nervous system (CNS) disorders has been considered relatively contraindicated. The fear of worsening neurologic outcome secondary to mechanical trauma, local anesthetic toxicity, or neural ischemia is commonly reported. We examined the frequency of new or progressive neurologic complications in patients with preexisting CNS disorders who subsequently underwent neuraxial blockade. The medical records of all patients at the Mayo Clinic from the period 1988 to 2000 with a history of a CNS disorder who subsequently received neuraxial anesthesia or analgesia were retrospectively reviewed. One-hundred-thirty-nine (n = 139) patients were identified for study inclusion. Mean patient age was 60 +/- 17 yr. Gender distribution was 86 (62%) males and 53 (38%) females. An established CNS disorder diagnosis was present a mean of 23 +/- 23 yr at the time of surgical anesthesia, with 74 (53%) patients reporting active neurologic symptoms. Spinal anesthesia was performed in 75 (54%) patients, epidural anesthesia or analgesia in 58 (42%) patients, continuous spinal anesthesia in 4 (3%) patients, and a combined spinal-epidural technique in 2 (1%) patients. Bupivacaine was the local anesthetic most commonly used in all techniques. Epinephrine was added to the injectate in 72 (52%) patients. There were 15 (11%) technical complications, with the unintentional elicitation of a paresthesia and traumatic needle placement occurring most frequently. A satisfactory block was reported in 136 (98%) patients. No new or worsening postoperative neurologic deficits occurred when compared to preoperative findings (0.0%; 95% confidence interval, 0.0%-0.3%). We conclude that the risks commonly associated with neuraxial anesthesia and analgesia in patients with preexisting CNS disorders may not be as frequent as once thought and that neuraxial blockade should not be considered an absolute contraindication within this patient population.

Exacerbation of preexisting neurological deficits by neuraxial anesthesia: report of 7 cases

We undertook this case series to determine if preexisting neurological disease is exacerbated by either spinal or epidural anesthesia. In the website of the Arachnoiditis Foundation, we posted an offer to advise anesthesiologists in cases of neurological problems after either of these techniques was used. Contacts were made first by way of the Internet, confirmed by telephone, and maintained by fax, e-mail, or by special mail. Patients here described were cared for and observed by one of the authors, in a hospital, in Argentina or in Mexico. A total of 7 adult, ASA physical status I and II patients, including 3 men and 4 women, with subtle symptoms of neurological disease before anesthesia, are described. Two patients had continuous lumbar epidural anesthesia, 3 had spinals; in 2 more, attempted epidural blocks led to accidental dural puncture and were converted to subarachnoid anesthetics. All patients accepted neuraxial anesthesia without informing the anesthesiologists that they had mild neurological symptoms before surgery. Because anesthesiologists did not specifically inquire about subclinical neurological symptoms or prior neurological disease, anesthesiologists are advised to carefully inquire about prior neurological disease whether neuraxial anesthesia techniques are considered.

Neurological disease in pregnancy

Abstract Neurological disease presents a particular challenge to those providing obstetric care, to minimise maternal, foetal and neonatal morbidity. Women with pre-existing neurological disease should ideally be given a preconceptual assessment in order to optimise medical management. Headache is an extremely common problem both during and outside of pregnancy and requires a structured approach. Some conditions, such as eclampsia, are unique to pregnancy, whereas others, such as carpal tunnel syndrome, are seen much more frequently but not exclusively in pregnancy. The drug management of epilepsy in pregnancy represents a particular challenge, balancing the desire to limit foetal exposure on the one hand, with the need to maintain therapeutic benefit to the mother on the other. Assessment of all neurological conditions requires a sound knowledge of neuroanatomy and the physiology of pregnancy, with appropriate use of neuroimaging and neurophysiological testing. Management should involve a multidisciplinary team with specialist neurological input.

Epiglottic carcinoma as a cause of laryngeal penetration and aspiration.

OBJECTIVE. The purpose of our investigation was to review a series of patients with epiglottic carcinoma to elucidate the clinical and videofluoroscopic findings in these individuals. CONCLUSION. Patients with epiglottic carcinoma often present with symptoms of aspiration or pharyngeal dysphagia of relatively brief duration in the absence of a preexisting neurologic disease. In this clinical setting, barium studies are useful not only for detecting the epiglottic carcinoma but also for delineating the presence and mechanism of laryngeal penetration or tracheobronchial aspiration.

Impact of Morphologic Characteristics of Central Pulmonary Thromboemboli in Massive Pulmonary Embolism

To assess the impact of morphologically different central pulmonary artery thromboemboli in patients with massive pulmonary emboli (MPEs) on short-term outcome. A prospective registry of consecutive patients. An 11-bed closed medical ICU at a 860-bed community general hospital Forty-seven patients with shock or hypotension due to MPE and central pulmonary thromboemboli detected by transesophageal echocardiography who were treated with thrombolysis between January 1994 and April 2000. Patients were divided into two groups according to the following characteristics of the detected thromboemboli: group 1, thrombi with one or more long, mobile parts; and group 2, immobile thrombi. Right heart catheterization was performed. The incidence of both types of thromboemboli was comparable. Groups 1 and 2 showed no differences in demographic data, risk factors for pulmonary embolism, length of preceding clinical symptoms, percentage of patients in shock, hemodynamic variables, serum lactate levels on hospital admission, and treatment. Seven fatal cases due to obstructive shock and right heart failure were present in group 2, but none were present in group 1 (7 of 23 patients vs 0 of 24 patients, respectively; p < 0.05). At 12 h, the cardiac index was lower in group 2 than in group 1 (2.6 +/- 1.0 vs 3.1 +/- 0.9 L/min/m(2), respectively; p < 0.05), and the central venous pressure (15.0 +/- 6.2 vs 12.5 +/- 3.7 mm Hg, respectively; p < 0.05) and total pulmonary resistance (12.9 +/- 5.9 vs 8.6 +/- 2.7 mm Hg/L/min/m(2), respectively; p < 0.001) were higher in group 2 compared to group 1. On hospital admission, inclusion in group 2 (p < 0.03; hazard ratio, 9.53; 95% confidence interval [CI], 1.19 to 76.47) and preexisting chronic medical or neurologic disease (p < 0.01; hazard ratio, 16.4; 95% CI, 1.97 to 136.3) were independent predictors of 30-day mortality. On hospital admission, morphology of the thromboemboli and the presence of pre-existing chronic medical or neurologic disease are independent predictors of 30-day mortality. Patients with immobile central pulmonary thromboemboli have a worse short-term outcome than those with mobile central pulmonary thromboemboli.