Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke

Tenecteplase-associated orolingual angioedema: A case report and literature review

PURPOSE

Orolingual angioedema (OA) secondary to administration of thrombolytic therapy is a rare, but serious, known adverse effect. Despite the lack of robust evidence for their use, C1 esterase inhibitors are recommended by guidelines for the treatment of refractory thrombolytic-associated OA. This report highlights the use of a C1 esterase inhibitor in a patient with tenecteplase-associated OA unresolved by antihistamine and corticosteroid therapy.

SUMMARY

A 67-year-old white male with a history of hypertension managed with lisinopril presented to the emergency department with acute onset of slurred speech and left-sided hemiparesis. Following workup, an outside hospital's neurology stroke team suspected an acute infarct and determined the patient to be a candidate for tenecteplase. Approximately 1 hour after tenecteplase administration, the patient began complaining of dyspnea and mild oral angioedema. Immediate interventions for OA management included intravenous therapy with dexamethasone 10 mg, diphenhydramine 25 mg, and famotidine 20 mg. After an additional 30 minutes, the patient's OA symptoms continued to progress and a C1 esterase inhibitor (Berinert) was administered. Shortly after administration of the C1 esterase inhibitor, the patient's symptoms continued to worsen, ultimately leading to endotracheal intubation. Following intubation, symptom improvement was noted, and the patient was safely extubated after 30 hours.

CONCLUSION

Although rare, OA is a potentially life-threatening complication of tenecteplase therapy and requires prompt pharmacological intervention to optimize patient outcomes. Currently, no single agent or treatment algorithm exists that has shown significant efficacy or safety in the setting of thrombolytic-associated OA. Until data are available for C1 esterase inhibitors in this application, these inhibitors should only be considered if there is continued symptom progression after intravenous administration of corticosteroids and antihistamines.

Neurologic and Psychiatric Manifestations of Bradykinin-Mediated Angioedema: Old and New Challenges

Neurologic manifestations have been occasionally described in patients with bradykinin-mediated angioedema. The existing literature is currently limited to case series and case reports mainly described in the hereditary forms (HAE) concerning central nervous system (CNS) involvement. On the contrary, very little is known about peripheral and autonomic nervous system manifestations. CNS involvement in HAE may present with symptoms including severe headaches, visual disturbance, seizures, and various focal and generalized deficits. In addition, a stroke-like clinical picture may present in HAE patients. In turn, some drugs used in patients with cardiovascular and neurologic disorders, such as recombinant tissue plasminogen activator (r-tPA) and angiotensin-converting enzyme inhibitors (ACEI), may produce medication-induced angioedema, resulting in a diagnostic challenge. Finally, most patients with HAE have higher levels of psychological distress, anxiety, and depression. With this review, we aimed to provide an organized and detailed analysis of the existing literature on neurologic and psychiatric manifestations of HAE to shed light on these potentially invalidating symptoms and lay the foundation for further personalized diagnostic pathways for patients affected by this protean disease.

Factor XII Structure-Function Relationships

Factor XII (FXII), the zymogen of the protease FXIIa, contributes to pathologic processes such as bradykinin-dependent angioedema and thrombosis through its capacity to convert the homologs prekallikrein and factor XI to the proteases plasma kallikrein and factor XIa. FXII activation and FXIIa activity are enhanced when the protein binds to a surface. Here, we review recent work on the structure and enzymology of FXII with an emphasis on how they relate to pathology. FXII is a homolog of pro-hepatocyte growth factor activator (pro-HGFA). We prepared a panel of FXII molecules in which individual domains were replaced with corresponding pro-HGFA domains and tested them in FXII activation and activity assays. When in fluid phase (not surface bound), FXII and prekallikrein undergo reciprocal activation. The FXII heavy chain restricts reciprocal activation, setting limits on the rate of this process. Pro-HGFA replacements for the FXII fibronectin type 2 or kringle domains markedly accelerate reciprocal activation, indicating disruption of the normal regulatory function of the heavy chain. Surface binding also enhances FXII activation and activity. This effect is lost if the FXII first epidermal growth factor (EGF1) domain is replaced with pro-HGFA EGF1. These results suggest that FXII circulates in blood in a "closed" form that is resistant to activation. Intramolecular interactions involving the fibronectin type 2 and kringle domains maintain the closed form. FXII binding to a surface through the EGF1 domain disrupts these interactions, resulting in an open conformation that facilitates FXII activation. These observations have implications for understanding FXII contributions to diseases such as hereditary angioedema and surface-triggered thrombosis, and for developing treatments for thrombo-inflammatory disorders.

Retropharyngeal hematoma mimicking angioedema after intravenous thrombolysis for acute ischemic stroke

Tissue plasminogen activator (tPA) is a cornerstone treatment for acute ischemic stroke (AIS). Administration of tPA is not without risk, and can provoke life threatening adverse reactions. Retropharyngeal hematoma (RPH) following tPA administration has only been reported after tenecteplase (TNK) administration for ST elevation myocardial infarction (STEMI). A 78 year old patient received tPA for AIS. Following administration of tPA, this patient developed acute signs and symptoms of what appeared to be a more well-known adverse reaction of tPA administration - angioedema. After CT and laboratory findings, our patient received cryoprecipitate for tPA reversal. Our case highlights a unique case of RPH mimicking angioedema following tPA administration.

A mechanism for hereditary angioedema caused by a lysine 311-to-glutamic acid substitution in plasminogen

Patients with hereditary angioedema (HAE) experience episodes of bradykinin (BK)-induced swelling of skin and mucosal membranes. The most common cause is reduced plasma activity of C1 inhibitor, the main regulator of the proteases plasma kallikrein (PKa) and factor XIIa (FXIIa). Recently, patients with HAE were described with a Lys311 to glutamic acid substitution in plasminogen (Plg), the zymogen of the protease plasmin (Plm). Adding tissue plasminogen activator to plasma containing Plg-Glu311 vs plasma containing wild-type Plg (Plg-Lys311) results in greater BK generation. Similar results were obtained in plasma lacking prekallikrein or FXII (the zymogens of PKa and FXIIa) and in normal plasma treated with a PKa inhibitor, indicating Plg-Glu311 induces BK generation independently of PKa and FXIIa. Plm-Glu311 cleaves high and low molecular weight kininogens (HK and LK, respectively), releasing BK more efficiently than Plm-Lys311. Based on the plasma concentrations of HK and LK, the latter may be the source of most of the BK generated by Plm-Glu311. The lysine analog ε-aminocaproic acid blocks Plm-catalyzed BK generation. The Glu311 substitution introduces a lysine-binding site into the Plg kringle 3 domain, perhaps altering binding to kininogens. Plg residue 311 is glutamic acid in most mammals. Glu311 in patients with HAE, therefore, represents reversion to the ancestral condition. Substantial BK generation occurs during Plm-Glu311 cleavage of human HK, but not mouse HK. Furthermore, mouse Plm, which has Glu311, did not liberate BK from human kininogens more rapidly than human Plg-Lys311. This indicates Glu311 is pathogenic in the context of human Plm when human kininogens are the substrates.

Photoacoustic imaging of 3D-printed vascular networks

Thrombosis in the circulation system can lead to major myocardial infarction and cardiovascular deaths. Understanding thrombosis formation is necessary for developing safe and effective treatments. In this work, using digital light processing (DLP)-based 3D printing, we fabricated sophisticatedin vitromodels of blood vessels with internal microchannels that can be used for thrombosis studies. In this regard, photoacoustic microscopy (PAM) offers a unique advantage for label-free visualization of the 3D-printed vessel models, with large penetration depth and functional sensitivity. We compared the imaging performances of two PAM implementations: optical-resolution PAM and acoustic-resolution PAM, and investigated 3D-printed vessel structures with different patterns of microchannels. Our results show that PAM can provide clear microchannel structures at depths up to 3.6 mm. We further quantified the blood oxygenation in the 3D-printed vascular models, showing that thrombi had lower oxygenation than the normal blood. We expect that PAM can find broad applications in 3D printing and bioprinting forin vitrostudies of various vascular and other diseases.

[Orolingual Angioedema after Recombinant Tissue Plasminogen Activator Treatment in Acute Cardiogenic Cerebral Embolism Patient Using Olmesartan: A Case Report]

Recombinant tissue plasminogen activator (rt-PA), which is used to treat acute cerebral infarction, may cause angioedema immediately after administration particularly in patients who are taking angiotensin-converting enzyme (ACE) inhibitors. On the other hand, unlike ACE inhibitors, angiotensin II receptor blockers (ARBs) do not act directly on bradykinin, and are therefore considered an alternative to ACE inhibitors in patients with bradykinin-related side effects. We report a case of orolingual angioedema in an 82-year-old male patient who is taking ARB, which occurred after rt-PA administration for acute cerebral infarction. The patient, who has been on medications for hypertension including ARB (olmesartan 40 mg/day) and for hyperuricemia, was transported to our hospital with the chief complaint of right conjugate deviation of the eyes and left hemiplegia. Head magnetic resonance imaging revealed cerebral infarction in the right mesencephalic artery area including the insular cortex. He was diagnosed with cardiogenic cerebral embolism, and rt-PA administration was started 4 h after onset. The patient developed eyelid edema 2.5 h after the start of administration, and orolingual angioedema and breathing difficulty 15.5 h after. The patient was treated with methylprednisolone, d-chlorpheniramine maleate, and famotidine, and the symptoms improved gradually in 1.5 h. We should pay attention to the occurrence of orolingual angioedema not only at the beginning of rt-PA administration but also for a long time thereafter when it is used in patients taking ARBs.

An Overview of Clinically Imperative and Pharmacodynamically Significant Drug Interactions of Renin-Angiotensin-Aldosterone System (RAAS) Blockers

INTRODUCTION

Hypertension is a leading cause of cardiovascular disease and chronic kidney disease, resulting in premature death and disability. The Renin-Angiotensin-Aldosterone System (RAAS) blockers, including Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs), are used as first-line antihypertensive therapy to treat hypertensive patients with comorbidities, including diabetes, ischemic heart disease, heart failure, and chronic kidney disease. The use of RAS blockers is associated with the risks, such as hyperkalemia, angioedema, etc. The drugs potentiating them interact pharmacodynamically, resulting in adverse consequences. This review article focuses on the clinically important drug interactions of RAAS blockers.

MATERIALS AND METHODS

The electronic databases, such as Medline/PubMed Central/PubMed, Google Scholar, ScienceDirect, Cochrane Library, Directory of Open Access Journals (DOAJ), Embase, and reference lists were searched to identify relevant articles.

RESULTS

The risk of hyperkalemia may be enhanced potentially in patients receiving a RAS blocker and potassium-sparing diuretics, potassium supplements, trimethoprim, adrenergic betablockers, antifungal agents, calcineurin inhibitors, pentamidine, heparins or an NSAID, concomitantly. The patients taking ACE inhibitors and mTOR inhibitors, DPP4 inhibitors, alteplase, or sacubitril/valsartan concurrently may be at increased risk of developing angioedema.

CONCLUSION

Clinicians, pharmacists, and other healthcare practitioners should be accountable for medication safety. To avoid adverse implications, prescribers and pharmacists must be aware of the drugs that interact with RAAS blockers.

Neurological complications of cardiovascular drugs

Cardiovascular drugs are used to treat arterial hypertension, hyperlipidemia, arrhythmias, heart failure, and coronary artery disease. They also include antiplatelet and anticoagulant drugs that are essential for prevention of cardiogenic embolism. Most neurologic complications of the cardiovascular drugs are minor or transient and are far outweighed by the anticipated benefits of treatment. Other neurologic complications are more serious and require early recognition and management. Overtreatment of arterial hypertension may cause lightheadedness or fatigue but often responds readily to dose adjustment or an alternative drug. Other drug complications may be more troublesome as in myalgia associated with statins or headache associated with vasodilators. The recognized bleeding risk of the antithrombotics requires careful calculation of risk/benefit ratios for individual patients. Many neurologic complications of cardiovascular drugs are well documented in clinical trials with known frequency and severity, but others are rare and recognized only in isolated case reports or small case series. This chapter draws on both sources to report the adverse effects on muscle, nerve, and brain associated with commonly used cardiovascular drugs.

Tissue Plasminogen Activator-Induced Angioedema Involving a Posterior Cerebral Artery Infarct: A Case Presentation

Patient: Female, 84-year-old

Final Diagnosis: Angioedema

Symptoms: Angioedema

Medication:—

Clinical Procedure: —

Specialty: Critical Care Medicine • General and Internal Medicine

Unilateral orolingual angioedema in a patient with sarcoidosis after intravenous thrombolysis due to acute stroke without improvement after treatment with icatibant

A potential complication after intravenous administration of recombinant tissue plasminogen activators (rtPAs) for thrombolysis in acute ischaemic stroke is orolingual angioedema, with an incidence of 0.4%–7.9%. In the herewith reported case, we discuss potential links between a history of sarcoidosis and the occurrence of orolingual angioedema after rtPA administration. Sarcoidosis is often accompanied by an elevated ACE level. In contrast, low ACE levels appear to play a role in the pathomechanism currently assumed to trigger angioedema, that is, the activation of the bradykinin and complement pathways. Medication with ACE inhibitors is considered a risk factor for angioedema. Based on these considerations, the patient was also treated with icatibant, a bradykinin B2-receptor antagonist, which has been found useful in recent publications on treating orolingual angioedema after intravenous lysis in ischaemic stroke.

Fibrinolytics for the treatment of pulmonary embolism

The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. Fibrinolysis is generally not recommended for routine use in intermediate-risk PE, although most guidelines advise that it may be considered in patients with signs of acute decompensation and an overall low bleeding risk. The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.

Nontraumatic Head and Neck Emergencies

Head and neck imaging is an intimidating subject for many radiologists because of the complex anatomy and potentially serious consequences of delayed or improper diagnosis of the diverse abnormalities involving this region. The purpose of this article is to help radiologists to understand the intricate anatomy of the head and neck and to review the imaging appearances of a variety of nontraumatic head and neck conditions that bring patients to the emergency department, including acute infectious and inflammatory diseases and acute complications of head and neck neoplasms. These conditions are presented in five sections on the basis of their primary location of involvement: the oral cavity and pharynx, neck, sinonasal tract, orbits, and ears. Important anatomic landmarks are reviewed briefly in each related section.Online supplemental material is available for this article.^©RSNA, 2019.

Angioedemas associated with renin-angiotensin system blocking drugs: Comparative analysis of spontaneous adverse drug reaction reports

INTRODUCTION

Angioedema is a subcutaneous swelling typically affecting the face, larynx or pharynx. It is a known adverse drug reaction (ADR) of ACE inhibitors (ACEi), angiotensin-II-receptor blockers (ARBs) and aliskiren (renin inhibitor). Several studies have reported pathophysiological mechanisms and risk factors of ACEi-associated angioedemas, whereas little is known for ARBs and aliskiren. The aim of the study was to analyze comparatively ACEi versus ARBs and aliskiren angioedema reports contained in the European ADR database EudraVigilance with regard to reported risk factors and clinical phenotypes.

METHODS

All spontaneous angioedema reports received between 01/2010-06/2017 reporting either an ACEi, ARB, or aliskiren as "suspected/interacting" drug were identified using the Standardized MedDRA Query "angioedema (narrow)". In order to perform a comparative analysis, odds ratios (ORs) were calculated for angioedema reports of ACEi (n = 3.194) versus ARBs (n = 687) and aliskiren (n = 162).

RESULTS

More patients with a history of allergy were included in angioedema reports of ARBs (6.8%) and aliskiren (13.6%) versus ACEi (4.3%). "Urticaria" as an ADR was reported more frequently in angioedema reports of ARBs (18.5%) and aliskiren (9.0%) versus ACEi (5.0%). ACEi-associated angioedemas were more often designated as "life-threatening" compared to ARBs (OR 2.2 [1.6-2.9]) and aliskiren-associated angioedemas (OR 14.2 (3.5-57.4). Concomitant therapy with mTOR inhibitors (OR 4.3 [1.0-17.9]) and fibrinolytics (OR 7.8 [1.1-57.2]) was reported more often in ACEi versus ARBs angioedema reports.

CONCLUSION

The reported clinical phenotypes differed between ACEi versus ARBs and aliskiren angioedema reports. Differences between the patient populations as observed in our study or differences with regard to underlying pathomechanisms could account for this finding. Due to the methodological limitations of spontaneous reporting systems, we cannot draw a firm conclusion in this regard. Hence, further research is necessary to confirm our observation and elucidate the underyling causes.

Angioedema associated with thrombolysis for ischemic stroke: analysis of a case-control study

BACKGROUND

Bradykinin-mediated angioedema (AE) is a complication associated with thrombolysis for acute ischemic stroke. Risk factors are unknown and management is discussed.

OBJECTIVES

To clarify risk factors associated with bradykinin-mediated AE after thrombolysis for acute ischemic stroke.

METHODS

In a case-control study conducted at a French reference centre for bradykinin angiœdema, patients with thrombolysis for acute ischemic stroke and a diagnosis of bradykinin-mediated angiœdema, were compared to controls treated with thrombolysis treatment without angiœdema.

RESULTS

Fifty-three thrombolysis-related AE were matched to 106 control subjects. The sites of attacks following thrombolysis for ischemic stroke mainly included tongue (34/53, 64%) and lips (26/53, 49%). The upper airways were involved in 37 (70%) cases. Three patients required mechanical ventilation. Patients with bradykinin-mediated angiœdema were more frequently women [33 (62%) vs. 44 (42%); P = 0.01], had higher frequency of prior ischemic stroke [12 (23%) vs. 9 (8%); P = 0.01], hypertension [46 (87%) vs. 70 (66%); P = 0.005], were more frequently treated with angiotensin-converting enzyme inhibitor [37 (70%) vs. 28 (26%); P < 0.001] and were more frequently hospitalized in intensive care medicine [ICU; 11 (21%) vs. 5 (5%); P = 0.004]. In multivariate analysis, factors associated with thrombolysis-related AE were female sex [odds ratio (OR), 3.04; 95% confident interval (CI), 1.32-7.01; P = 0.009] and treatment with angiotensin-converting enzyme inhibitors [(OR), 6.08; 95% (CI), 2.17-17.07; P < 0.001].

CONCLUSIONS

This case-control study points out angiotensin-converting enzyme inhibitors and female sex as risk factors of bradykinin AE associated with thrombolysis for ischemic stroke.

Orolingual Angioedema After Tissue Plasminogen Activator Administration in Patients Taking Angiotensin-Converting Enzyme Inhibitors

Orolingual angioedema is a rare adverse effect (1%-5%) of tissue plasminogen activator (tPA) that can lead to significant morbidity in patients with acute ischemic stroke. It is thought that increased levels of bradykinin and histamine resulting from tPA administration can result in angioedema. Angiotensin-converting enzyme (ACE) inhibitors can also lead to increased levels of bradykinin and appear to be a risk factor for tPA-associated angioedema. A literature review was conducted to examine previous cases of orolingual angioedema associated with tPA administration in patients also taking ACE inhibitors to better understand the relationship between ACE inhibitors and tPA-induced angioedema. Over a 20-year period, 27 patients who experienced angioedema with tPA while on ACE inhibitor therapy were identified. In this patient population, the onset of angioedema symptoms appeared as soon as 15 min after the tPA bolus and as late as 2 hr after the tPA infusion. Most patients required a combination of supportive medications such as corticosteroids (81.5%), antihistamines (74%), and epinephrine (18.5%) for the management of angioedema. Severe presentations of orolingual angioedema resulted in intubation for airway protection (26%). Symptom resolution ranged from shortly after the administration of supportive medications to 72 hr after symptom onset. Orolingual angioedema after tPA administration has the potential to cause significant morbidity, indicating patients should be monitored closely for a few hours after administration for the development of airway compromise. ACE inhibitors should not be the preferred antihypertensive agents for patients who require blood pressure lowering prior to tPA administration.

Angioedema in Stroke Patients With Thrombolysis

Background and Purpose- Oral angioedema (OA) is a rare but life-threatening complication in patients with ischemic stroke receiving intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator). This study intended to determine associations between thrombolysis-related OA and ischemic stroke lesion sites using a voxel-wise lesion analysis. Methods- Prospective registry data were used to identify ischemic stroke patients with thrombolysis-related OA between 2002 and 2018. For the study registry, ethics approval was obtained by the Ethics Committee of the Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg (clinical registry registration: 377_17Bc). Ischemic stroke patients with thrombolysis treatment but without OA admitted in the years 2011 and 2012 comprised the control group. Ischemic lesions were manually outlined on magnetic resonance imaging (1.5T or 3T) or computed tomographic scans and transformed into stereotaxic space. We determined the lesion overlap and compared the absence or presence of OA voxel-wise between patients with and without lesions in a given voxel using the Liebermeister test. Stroke severity was rated using the National Institutes of Health Stroke Scale score, and blood pressure, heart rate, blood glucose levels, and body temperature were determined on admission. Results- Fifteen ischemic stroke patients with thrombolysis-related OA were identified. The voxel-wise analysis yielded associations between OA and ischemic lesions in the insulo-opercular region with a right hemispheric dominance. Mean blood pressure was significantly lower in patients with OA than in controls. Age, National Institutes of Health Stroke Scale scores, infarct volumes, heart rate, and blood glucose levels did not differ between patients with and without OA. Conclusions- The voxel-wise analysis linked thrombolysis-related OA to right insulo-opercular lesions. The lower blood pressure in patients with thrombolysis-related OA may reflect bradykinin effects causing vasodilatation and increasing vascular permeability.

Angioedema after thrombolysis with tissue plasminogen activator: an airway emergency

Recombinant tissue plasminogen activator (rtPA), an enzyme that catalyzes the conversion of plasminogen to plasmin resulting in fibrinolysis, is used for the treatment of acute ischemic strokes. The use of this medication is not without complication. One complication of this therapy is angioedema. This complication can be life-threatening if not recognized quickly. However, the potential for the development of angioedema after rtPA administration is not widely known. This is a case of a 60-year-old man who suffered an acute ischemic stroke and was given rtPA. The patient subsequently developed rapidly progressing angioedema leading to airway compromise. The patient was intubated with some difficulty and the angioedema improved and the patient was able to be extubated the next day. Angioedema secondary to administration of rtPA is thought to be bradykinin mediated, but the exact mechanism is unknown. Treatment with FFP, Icatibant, Ecallantide or a C1-esterase inhibitor can be considered.

Institutional Incidence of Severe tPA-Induced Angioedema in Ischemic Cerebral Vascular Accidents

Introduction

Tissue plasminogen activator (tPA) is commonly used in ischemic cerebral vascular accidents (CVAs). tPA is generally well tolerated; however, orolingual angioedema is a well-documented adverse effect. Angioedema is generally mild, transient, and unilateral but can manifest as severe, life-threatening upper airway obstruction requiring intubation. Reported incidence for all severities ranges from one to five percent, whereas reported incidence of severe cases ranges from 0.18 to 1 percent of patients receiving tPA for ischemic CVA. Angiotensin-converting enzyme (ACE) inhibitors and middle cerebral artery distribution have been associated with a higher risk of developing angioedema. The aim of this study is to evaluate the incidence of severe tPA-induced angioedema and its effects on length of stay (LOS) and death.

Methods

A retrospective chart review of patients receiving tPA for ischemic CVA from January 2014 through December 2016 was conducted at a large tertiary center with Comprehensive Stroke Center designation. Subjects were eighteen or older. Baseline demographics and clinical data were collected.

Results

147 patients were included with four developing severe angioedema due to tPA resulting in an incidence of 2.72%. All four were female. The median LOS was thirty days for patients with angioedema and twelve days for those without. The survival probability was higher in the angioedema group and mean time to death was twenty-two days in the angioedema group and twenty-one days in the nonangioedema group. Twenty-five patients died, one from the angioedema group. ACE inhibitor use was found to have an OR of 7.72.

Conclusion

This study found a higher incidence of severe angioedema than that reported. Development of severe angioedema increased length of stay but was not shown to worsen outcomes in regards to death. Consistent with previous studies, ACE inhibitor use was associated with a higher risk of developing angioedema.

Orolingual angioedema to alteplase. Identify, counsel and monitor at risk patients

Orolingual angioedema (OLA) is a known complication of intravenous alteplase used to treat ischaemic stroke. The incidence may be as high as 5.1%. ACE inhibitors are thought to increase the risk of developing this potentially life-threatening complication. This case report demonstrates how we may improve in the identification of risk factors in the history; the counselling of patients appropriately; in seeking alternative therapies such as mechanical thrombectomy; and in the monitoring of patients for signs of OLA once alteplase has been given.

Orolingual Angioedema During or After Thrombolysis for Cerebral Ischemia

Background and Purpose—

Orolingual angioedema (OLAE) is a life-threatening complication of intravenous thrombolysis. Our objective was to compare outcomes of patients with and without OLAE.

Methods—

We prospectively included consecutive patients who received intravenous thrombolysis for cerebral ischemia at Lille University Hospital. We examined tongue and lips every 15 minutes during thrombolysis and ≤30 minutes after. We evaluated the 3-month outcome with the modified Rankin scale (mRS) and compared outcomes of patients with and without OLAE.

Results—

Of 923 consecutive patients, 20 (2.2%) developed OLAE. None of them needed oro-tracheal intubation. They were more likely to be under angiotensin-converting enzyme inhibitors (adjusted odds ratio [adjOR], 3.9; 95% confidence interval [CI], 1.6–9.7; P =0.005) to have total insular infarcts (OR, 5.0; 95% CI, 1.5–16.5; P =0.004) and tended to develop more symptomatic intracerebral hemorrhages. Results concerning angiotensin-converting enzyme inhibitors were not modified after adjustment for propensity scores (OR, 4.4; 95% CI, 1.6–11.9; P =0.004) or matched analysis based on propensity scores (OR, 3.4; 95% CI, 1.3–8.1; P =0.010). Patients with OLAE did not significantly differ at 3 months for the proportion of patients with mRS score of 0 to 1 (adjOR, 0.9; 95% CI, 0.3–2.1), mRS score of 0 to 2 (adjOR, 0.8; 95% CI, 0.1–1.8), and death (adjOR, 1.1; 95% CI, 0.3–3.8).

Conclusions—

OLAE occurs in 1 of 50 patients who receive intravenous thrombolysis, 1 of 10 in case of total insular infarct, and 1 of 6 if they are under angiotensin-converting enzyme inhibitors. Their long-term outcome does not differ from that of other patients.

Cardiovascular Instability Preceded by Orolingual Angioedema after Alteplase Treatment

An 87-year-old man taking antihypertensive medications, including 10 mg enalapril, daily visited our hospital complaining of motor aphasia, dysarthria, and right hemiparesis. Magnetic resonance imaging revealed an ischemic lesion in the left frontal lobe including the insular cortex and severe stenosis of the left middle cerebral artery. After he received intravenous alteplase infusion, he developed orolingual angioedema followed by transient bradycardia with subsequent hypotension, resulting in the deterioration of his neurological signs and expansion of the ischemic lesion. Orolingual angioedema after intravenous alteplase infusion may follow cardiovascular instability and disease progression in stroke patients.

Persistent, severe post-thrombolysis angioedema: Simple management of a difficult problem

Post-thrombolysis orolingual angioedema in the setting of managing acute stroke is reported in the literature as most often being mild and self-limiting. We present a case of severe angioedema resulting in persistent macroglossia, representing a different end of the spectrum of disease than that referenced in the literature. Despite the severity of the tongue edema in our case, it did resolve with a relatively simple intervention. In addition to highlighting that post-thrombolysis angioedema can be potentially life threatening, this report reviews the pathophysiology of this condition and discusses management options for macroglossia in this setting.

Management of Postthrombolysis Hemorrhagic and Orolingual Angioedema Complications

Intravenous recombinant tissue plasminogen activator was first approved for the treatment of acute ischemic stroke in the United States in 1996. Thrombolytic therapy has been proven to be effective in acute ischemic stroke treatment and shown to improve long-term functional outcomes. Its use is associated with an increased risk of symptomatic intracerebral hemorrhage as well as orolingual angioedema. Our goal is to outline the management strategies for these postthrombolysis complications.

Clinical Presentation, Imaging, and Management of Complications due to Neurointerventional Procedures

Neurointervention is a rapidly evolving and complex field practiced by clinicians with backgrounds ranging from neurosurgery to radiology, neurology, cardiology, and vascular surgery. New devices, techniques, and clinical applications create exciting opportunities for impacting patient care, but also carry the potential for new iatrogenic injuries. Every step of every neurointerventional procedure carries risk, and a thorough appreciation of potential complications is fundamental to maximizing safety. This article presents the most frequent and dangerous iatrogenic injuries, their presentation, identification, prevention, and management.

Incidence, predictors and clinical characteristics of orolingual angio-oedema complicating thrombolysis with tissue plasminogen activator for ischaemic stroke

BACKGROUND

Orolingual angio-oedema is a recognised complication of tissue plasminogen activator (tPA) for ischaemic stroke. We investigated its incidence, clinical characteristics and relationship with other factors in patients receiving tPA at a UK centre.

METHODS

530 consecutive patients (median age 70 years) receiving tPA treatment for confirmed ischaemic stroke were included. Cases were defined as those developing angio-oedema within 24 h of initiation of tPA. Angio-oedema was retrospectively classified as mild, moderate or severe using predefined criteria. The primary analysis was the association between prior ACE inhibitor (ACE-I) treatment and angio-oedema.

RESULTS

Orolingual angio-oedema was observed in 42 patients (7.9%; 95% CI 5.5% to 10.6%), ranging from 5 to 189 min after initiation of tPA (median 65 min). 12% of the angio-oedema cases were severe (1% of all patients treated with tPA), requiring urgent advanced airway management. 172 patients (33%) were taking ACE-I. In multifactorial analyses, only prior ACE-I treatment remained a significant independent predictor of angio-oedema (odds ratio (OR) 2.3; 95% CI 1.1 to 4.7).

CONCLUSIONS

Angio-oedema occurs more frequently than previously reported and is associated with preceding ACE-I treatment. Angio-oedema may be delayed and progress to life-threatening airway compromise, which has implications for the assessment and delivery of thrombolysis.

Lingual angioedema after alteplase treatment in a patient with acute ischemic stroke

BACKGROUND

In recent years, thrombolytic therapy has become the main treatment of ischemic stroke. But the increasing use of alteplase in ischemic stroke has made some complications more evident. Angioedema is a rare but potentially life-threatening complication of alteplase treatment. Only a few studies have examined the incidence of angioedema after treatment with alteplase for stroke.

METHODS

A 75-year-old man complaining of right hemiparesis was admitted to our emergency department. He was diagnosed as having acute ischemic stroke, and alteplase infusion was given two hours after the onset of stroke symptoms. Immediately after the completion of infusion he was noted to have a large swollen tongue.

RESULTS

His neurological symptoms resolved gradually within 4 hours, whereas his upper extremity strength improved to 4/5 and lower extremity 5/5. Lingual edema resolved within 16 hours without any complication. He died from presumed nosocomial infection 5 days later.

CONCLUSIONS

Lingual angioedema may appear as a possible complication in patients who were treated with alteplase. The management of these patients should be very careful.

Angioedema in the neurointerventional suite

A 68-year-old woman with acute ischemic stroke presented for mechanical thrombectomy, after failed thrombolysis with intravenous recombinant tissue plasminogen activator. The procedure was completed successfully with dexmedetomidine infusion. However, she developed acute angioedema toward the end of the procedure requiring emergent fiberoptic-guided endotracheal intubation. Angioedema has been reported to occur after administering intravenous recombinant tissue plasminogen activator with an incidence of 1.3%-5.1% in patients with acute stroke.

Asymmetric oro-facial angioedema following alteplase for acute ischaemic stroke

We present a patient with asymmetric oro-facial angioedema following thrombolysis for acute ischaemic stroke with serial photographs of this phenomenon. We discuss the mechanism for the development of asymmetric oro-facial oedema following thrombolysis and suggest a management plan.

Onset of Orolingual Angioedema After Treatment of Acute Brain Ischemia with Alteplase Depends on the Site of Brain Ischemia: A Meta-analysis

Background:

Alteplase is used to treat acute ischemic stroke. However, it has several documented adverse effects, including the development of orolingual angioedema (OA). Although, OA is a rare side-effect, it is thought to be life-threatening and is difficult to treat. Until date, little is known about this condition and a better understanding of OA may contribute to improve the morbidity and mortality amongst patients that develop this condition.

Materials and Methods:

Using the PubMed and Medknow databases, we searched for peer reviewed published articles on OA after alteplase administration in 1950-2012. We gathered demographic data and investigated the relationship between the location of OA, neurological symptoms and the site of cerebral ischemia. In addition, we studied the effects of hypertensive premedication on OA development. We identified 19 published manuscripts that fulfilled our search criteria. These manuscripts reported 41 cases of OA after alteplase administration.

Results:

We found that this condition is associated with cerebral ischemia (P < 0.012) and that 65.9% (n = 27) of patients who developed OA had a hypertensive drug as a premedication.

Conclusions:

Although OA is a rare side-effect of alteplase, it can occur depending upon the localization of acute cerebral ischemia.

Stroke thrombolysis: where are we and where are we going?

Stroke is an important cause of death and disability throughout the world. Most strokes are ischaemic, caused by thrombotic or embolic occlusion of blood vessels. The advent of thrombolysis for acute ischaemic stroke has revolutionised the treatment of acute stroke in the developed world. The benefit of thrombolysis in acute stroke is very time-dependent, with the greatest benefit achieved when administered within 90 minutes of ictus, but trials demonstrating some benefit up to 4.5, and possibly 6 hours. This has revolutionised stroke treatment, with redesign of clinical pathways to try to ensure patients with suspected stroke reach a hospital with a thrombolysis service as quickly as possible. Clinical stroke services need to ensure that all acute stroke patients can be scanned, treated and admitted to stroke units without delay. Future research needs to address the prevention and better management of complications, such as secondary intracerebral haemorrhage and angioedema. In addition, the evidence base for direct intra-arterial intervention such as thrombectomy needs to be established.

Angioedema from recombinant TPA administration: case report and pathophysiology review

Angioedema is an uncommon, yet morbid, adverse reaction to recombinant tissue plasminogen activator (rtPA) administration for ischemic stroke. Orolingual edema may preclude completion of rtPA therapy and cause potential airway compromise. Few case reports and case series have examined the incidence of angioedema and anaphylaxis related to this common stroke therapy. We report a case of orolingual edema and bleeding in a patient who received rtPA for acute ischemic stroke who was concurrently on an angiotension-converting enzyme inhibitor and discuss the pathophysiology of this reaction.

Thrombolytic dosing in acute ischaemic stroke

Thrombolysis treatment for acute ischaemic stroke is effective if it is administered within 4.5 hours of stroke onset. Alteplase is a licensed thrombolytic treatment for ischaemic stroke. The dose of alteplase is dependent on a patient's weight. The stroke team involved in the administration of the treatment usually estimates a patient's weight prior to the treatment in order to ensure the correct dosage. This paper highlights the reliability of body weight estimates in determining the accuracy of thrombolysis dosing and the implication of dosing errors to post-thrombolysed patients.

Angioedema after tPA: what neurointensivists should know

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.