Angioedema after tPA: what neurointensivists should know

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.

Case report.

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.

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.