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.
Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. fugate.jennifer@mayo.edu
Jennifer E
JE
Fugate
Ejaaz A
EA
Kalimullah
Eelco F M
EF
Wijdicks
D000368:Aged; D000799:Angioedema / Q000139:chemically induced*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects; D003422:Critical Care / Q000379:methods*; D004347:Drug Interactions; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects; D006801:Humans; D008046:Lip; D020521:Stroke / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects*; D014059:Tongue
D000806:Angiotensin-Converting Enzyme Inhibitors; D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator