Abstract
Background
Angioedema is an underappreciated and potentially life-threatening complication of intravenous (IV) recombinant tissue plasminogen activator (rt-PA). Patients taking angiotensin converting enzyme (ACE) inhibitors are at increased risk of this rare complication.
Methods
Case report.
Results
A 74 year-old woman taking lisinopril for hypertension was treated with IV rt-PA for right hemispheric acute ischemic stroke. Shortly after completion of the rt-PA infusion, she developed asymmetric angioedema involving the tongue and left lower lip. No emergent airway intervention was needed. Following treatment with epinephrine, antihistamines, and corticosteroids, the edema resolved within 24 h. The patient made an excellent recovery from the ischemic stroke.
Conclusions
Orolingual angioedema can complicate rt-PA treatment of acute stroke and is often ipsilateral to the side of hemiparesis. Neurointensivists should be aware of this possibility, which is increased in patients taking ACE inhibitors. Epinephrine can be given safely in this scenario. Identification of high risk features may help guide decisions regarding early definitive airway management.
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References
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–7.
Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369:275–82.
Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998;352:1245–51.
Hill MD, Buchan AM. Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study. CMAJ. 2005;172:1307–12.
Hill MD, Lye T, Moss H, et al. Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. Neurology. 2003;60:1525–7.
Engelter ST, Fluri F, Buitrago-Tellez C, et al. Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke. J Neurol. 2005;252:1167–70.
Papamitsakis NI, Kuyl J, Lutsep HL, Clark WM. Benign angioedema after thrombolysis for acute stroke. J Stroke Cerebrovasc Dis. 2000;9:79–81.
Shaps HJ, Snyder GE, Sama AE, Rudolph GS. Airway compromise secondary to lingual hematoma complicating administration of tissue plasminogen activator for acute ischemic stroke. Ann Emerg Med. 2001;38:447–9.
Pancioli A, Brott T, Donaldson V, Miller R. Asymmetric angioneurotic edema associated with thrombolysis for acute stroke. Ann Emerg Med. 1997;30:227–9.
Molinaro G, Gervais N, Adam A. Biochemical basis of angioedema associated with recombinant tissue plasminogen activator treatment: an in vitro experimental approach. Stroke. 2002;33:1712–6.
Hill MD, Barber PA, Takahashi J, Demchuk AM, Feasby TE, Buchan AM. Anaphylactoid reactions and angioedema during alteplase treatment of acute ischemic stroke. CMAJ. 2000;162:1281–4.
Grant NN, Deeb ZE, Chia SH. Clinical experience with angiotensin-converting enzyme inhibitor-induced angioedema. Otolaryngol Head Neck Surg. 2007;137:931–5.
Al-Khudari S, Loochtan MJ, Peterson E, Yaremchuk KL. Management of angiotensin-converting enzyme inhibitor-induced angioedema. Laryngoscope. 2011;121:2327–34.
Abdelmalak B, Makary L, Hoban J, Doyle DJ. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. J Clin Anesth. 2007;19:370–3.
Puchner W, Egger P, Puhringer F, Lockinger A, Obwegeser J, Gombotz H. Evaluation of remifentanil as single drug for awake fiberoptic intubation. Acta Anaesthesiol Scand. 2002;46:350–4.
Schaeuble J, Heidegger T, Gerig HJ, Ulrilch B, TW S. Comparison of etomidate and propofol for fibreoptic intubation as part of an airway management algorithm:a prospective, randomizes, double-blind study. Eur J Anaesthesiol. 2005;22:762–7.
Kim YC, Lee SH, Noh GJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg. 2000;91:698–701.
Maertins M, Wold R, Swider M. Angioedema after administration of tPA for ischemic stroke: case report. Air Med J. 2011;30:276–8.
Walls RM, Pollack CV Jr. Successful cricothyrotomy after thrombolytic therapy for acute myocardial infarction: a report of two cases. Ann Emerg Med. 2000;35:188–91.
Bas M, Greve J, Stelter K, et al. Therapeutic efficacy of icatibant in angioedema induced by angiotensin-converting enzyme inhibitors: a case series. Ann Emerg Med. 2010;56:278–82.
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Fugate, J.E., Kalimullah, E.A. & Wijdicks, E.F.M. Angioedema After tPA: What Neurointensivists Should Know. Neurocrit Care 16, 440–443 (2012). https://doi.org/10.1007/s12028-012-9678-0
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DOI: https://doi.org/10.1007/s12028-012-9678-0