Case Presentation: A 54-year-old woman presented with left-sided numbness and weakness and was diagnosed with acute lacunar stroke. She received alteplase in the emergency department and began complaining of tongue swelling shortly after the infusion had completed. Exam noted left-sided lip and tongue swelling. IV methylprednisolone, epinephrine, diphenhydramine, and ranitidine were rapidly administered but airway protection with endotracheal intubation was required despite these interventions.Past medical history consisted of morbid obesity, tobacco use, hypothyroidism, and esophageal cancer. She had never taken an ACE inhibitor and had no personal or family history of hereditary or drug-induced angioedema.
Steroid and antihistamine therapy were continued in the Neurology ICU. Angioedema persisted for several days delaying extubated and she developed intubation-associated sinusitis. Despite these complications, she was readily transferred out of the ICU following extubation and she continues to have improvement in her left-sided stroke deficits.
Discussion: Angioedema is a rare complication of thrombolytics (2-7%) and is typically mild to moderate and self-resolving. This complication is thought to have no impact on outcome for patients with acute ischemic stroke, but cases of severe angioedema requiring intubation have been under represented in studies. Prior ACE inhibitor therapy has been found to be a significant predictor. While ACE inhibitor use was not a risk factor for our patient, it highlights the fact that both ACE inhibitor and fibrinolytic induced angioedema are bradykinin-mediated. Recent evidence supports the use of bradykinin antagonists in severe thrombolytic angioedema as resolution appears to be rapid, potentially decreasing need for intubation.
Conclusions: Acute severe angioedema with airway compromise can result from intravenous thrombolytic intervention for acute ischemic stroke.