An 88-year-old African American male with past medical history of chronic kidney disease stage IV, hypertension, atrial fibrillation, and gout presented to Methodist Dallas Medical Center emergency room on 5/13/2015 with acute onset right hemiparesis, numbness, right sided facial droop and slurred speech. Patients last known normal was 1.5 hours prior to arrival at ER. Code stroke was activated and teleneurology service was consulted. Stat CT scan was obtained, which showed no intracranial bleed. Teleneurologist and family agreed to administration of tPA. tPA was administered 1 hour after arrival to ER. Patient was admitted for observation in the neuro critical care ICU after administration of tPA. Patient was found to have moderate improvement in speech and minimal improvement in right sided weakness immediately after administration. Patient was examined 6 hours after administration of tPA and was found to have right sided lower lip swelling. No tongue swelling or stridor was found on exam. Patient was started on methylprednisolone 40mg IV Q6h and was closely monitored. Orolingual angioedema resolved without further complications within the next 2 hours. Patient had overall improved strength in right lower extremity and speech but had significant residual right upper extremity weakness. Transesophageal echo was performed which showed vegetation on posterior mitral valve leaflet. Blood cultures were obtained to rule out endocarditis and resulted negative. Patient was sent to a rehab facility, and was subsequently started on xarelto for anticoagulation.
Discussion:
Orolingual angioedema is a rare side effect of Tissue Plasminogen Activator (tPA) administration, with incidence per literature search to be between 1-5%. With increasing use of tPA for treatment of stroke, awareness needs to be raised regarding this potentially life threatening complication.
Conclusions:
This case serves as a reminder of the need for increased awareness and caution in regards to post-tPA monitoring. Routine inspection of the lips and oral cavity is necessary during and after the administration of tPA in stroke patients.