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

Hurford, Robert; Rezvani, Sean; Kreimei, Mohammad; Herbert, Annie; Vail, Andy; Parry‐Jones, Adrian; Douglass, Chris; Molloy, Jane; Alachkar, Hana; Tyrrell, Pippa J.; Smith, Craig J.

doi:10.1136/jnnp-2014-308097

Cited by 55 publications

(57 citation statements)

References 13 publications

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“…Prevalence of OA in patients with acute ischemic stroke treated with alteplase was 4.9%, which is in accordance to previous studies [1][2][3][4]7]. We found no significant differences in the frequency of insular cortex ischemic lesions on pre-thrombolysis CT, and early signs of insular cortex ischemia were not independent predictors of OA occurrence in multivariate analysis.…”

Section: Discussionsupporting

confidence: 80%

“…It consists of painless swelling of lips, tongue, face and occasionally oropharynx, occurring shortly after intravenous alteplase administration, which usually resolves during the first 24 h. Most case-control studies recognize use of angiotensin-converting enzyme inhibitors (ACE-I) as the main risk factor for occurrence of this potentially serious adverse event [1][2][3][4], and other authors found a higher frequency of insular ischemia in patients who developed angioedema [2,5]. In addition to contribute to several high order complex cerebral functions, insular cortex is known to mediate autonomic responses and it is involved in cardiac and vascular autonomic tone regulation and visceromotor control.…”

Section: Introductionmentioning

confidence: 99%

“…Orolingual angioedema (OA) is a well known early complication of alteplase when used for treatment of acute ischemic stroke, occurring in up to 7.9% of patients [1][2][3]. It consists of painless swelling of lips, tongue, face and occasionally oropharynx, occurring shortly after intravenous alteplase administration, which usually resolves during the first 24 h. Most case-control studies recognize use of angiotensin-converting enzyme inhibitors (ACE-I) as the main risk factor for occurrence of this potentially serious adverse event [1][2][3][4], and other authors found a higher frequency of insular ischemia in patients who developed angioedema [2,5].…”

Section: Introductionmentioning

confidence: 99%

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Orolingual angioedema after thrombolysis is not associated with insular cortex ischemia on pre-thrombolysis CT

Pinho

Alves

Oliveira³

et al. 2016

Journal of the Neurological Sciences

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Objective: Orolingual angioedema (OA) is a well known early complication of treatment with alteplase in ischemic stroke patients. Our aim was to study risk factors for OA in these patients, namely insular cortex ischemia. Methods: Retrospective case-cohort study using the prospective registry of all consecutive ischemic stroke patients submitted to intravenous thrombolysis with alteplase. Clinical data was retrieved from the registry and medical records. Two independent observers evaluated early signs of insular cortex ischemia on pre-thrombolysis computed tomography (CT) and of insular cortex infarct on early follow-up imaging. Univariate and multivariate analysis were performed to identify predictors of OA. Results: Of the 659 patients with acute ischemic stroke treated with alteplase, 32 developed OA (4.9%, 95%CI = 3.3-6.6). Frequency of early signs of insular cortex ischemia on pre-thrombolysis CT and of insular cortex infarct on follow-up imaging was similar in patients with and without OA (p = 0.241 and p = 0.145, respectively). The only independent predictors of OA occurrence were female sex (OR = 5.47, 95%CI = 1.98-15.10) and angiotensin-converting enzyme inhibitor (ACE-I) use (OR = 3.87, 95%CI = 1.71-8.75). Conclusions: Female sex and ACE-I use are independent risk factors for OA occurrence in ischemic stroke patients treated with alteplase. Early signs of insular cortex ischemia on pre-thrombolysis CT were not significantly associated with OA.

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Section: Discussionsupporting

confidence: 80%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Orolingual angioedema after thrombolysis is not associated with insular cortex ischemia on pre-thrombolysis CT

Pinho

Alves

Oliveira³

et al. 2016

Journal of the Neurological Sciences

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“…Most cases resolve spontaneously or with the use of corticosteroids or antihistamines. 19 Other allergic reactions to IV rtPA are rarely reported. 20 Neurological deterioration after IV rtPA is more than twice as likely to be caused by non-haemorrhagic factors (recurrent ischaemic stroke, brain swelling or non-attributable deterioration) than SICH.…”

Section: Complicationsmentioning

confidence: 99%

Thrombolysis and thrombectomy for acute ischaemic stroke

Tawil

Muir

2017

Clinical Medicine

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The likelihood of disability-free recovery after acute ischemic stroke is significantly improved by reperfusion either by intravenous thrombolytic drug treatment or with endovascular mechanical thrombectomy in selected cases. The use of intravenous thrombolysis is limited by the short treatment window and you need to assess individual balance of benefit and risk of symptomatic intracranial haemorrhage. Benefit is greater for shorter onset-to-reperfusion time intervals, requiring optimisation of pre-hospital and inhospital pathways. Symptomatic haemorrhage is more likely with more severe strokes, but a greater proportion of patients are left free of disability than suffer a treatmentrelated haemorrhage at all levels of severity. Extracranial haemorrhage and orolingual angioedema are less common complications. Endovascular mechanical thrombectomy can be used in selected patients with imaging-proven large artery occlusion. Successful therapy depends on well-organised services that can deliver treatment within a short time window at centres with adequate expertise to perform the procedure.

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“…After reading of these 53 articles, 18 were selected for the combined analysis. 11,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] Seventeen articles were published in English 11,[13][14][15][16][17][19][20][21][22][23][24][25][26][27][28][29] and 1 in German. 18 The flow chart of the selection of articles is presented in Figure. None of these 18 articles 11,13-29 reported information on the prestroke mRS, alcohol consumption, weight, NIHSS at 2 and 24 hours and at 7 days, presence of infarct on imaging at 22 to 36 hours, s-ICH, infection, malignant infarct, and outcome at 3 months.…”

Section: Review Of the Literaturementioning

confidence: 99%

Orolingual Angioedema During or After Thrombolysis for Cerebral Ischemia

Myslimi

Caparros

Dequatre‐Ponchelle

et al. 2016

Stroke

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We used data prospectively collected in a registry of consecutive patients treated with intravenous r-tPA for cerebral ischemia in the stroke center of the Lille University Hospital, from September 30, 2003 to February 4, 2015. The general organization, 4,5 eligibility criteria for thrombolysis, 2,6,7 clinical assessment, 8-10 imaging procedures, and treatment administration 7 have been previously described. 4,5 Patients from this cohort were included in previous studies of our group including one in which the occurrence of OLAE was reported 11 and in a case report. 12Background 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, 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.

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

Abstract: 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.

Cited by 55 publications

References 13 publications

Orolingual angioedema after thrombolysis is not associated with insular cortex ischemia on pre-thrombolysis CT

Orolingual angioedema after thrombolysis is not associated with insular cortex ischemia on pre-thrombolysis CT

Thrombolysis and thrombectomy for acute ischaemic stroke

Orolingual Angioedema During or After Thrombolysis for Cerebral Ischemia

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