Tissue Plasminogen Activator-Induced Angioedema Involving a Posterior Cerebral Artery Infarct: A Case Presentation

Abstract

Patient: Female, 84-year-old Final Diagnosis: Angioedema Symptoms: Angioedema Medication:— Clinical Procedure: — Specialty: Critical Care Medicine • General and Internal Medicine Objective: Unusual clinical course Background: Angioedema is characterized by localized swelling of subcutaneous or submucosal tissue resulting from fluid extravasation due to the loss of vascular integrity. It most commonly occurs with exposure to allergens and certain medications, namely nonsteroidal anti-inflammatory agents and angiotensin-converting enzyme inhibitors. There have been few incidences of angioedema following the administration of tissue plasminogen activator. Case Report: We describe an 84-year-old woman with a history of hypertension managed with lisinopril who presented with an acute onset of right-sided hemiparesis, slurred speech, and right-sided hemianopsia. Urgent computed tomography of the head revealed subacute infarct of the left pons without hemorrhage. Intravenous alteplase was administered and within 30 min our patient developed severe orolingual edema requiring emergent intubation. Subsequent imaging revealed acute to subacute infarct of the left occipital lobe in the posterior cerebral artery region, consistent with her initial presenting symptoms. Conclusions: Angioedema induced by tissue plasminogen activator occurs in approximately 1–5% of patients receiving thrombolysis for ischemic stroke and can be life-threatening. The risk is increased in patients taking angiotensin-converting enzyme inhibitors, in patients with ischemic strokes of the middle cerebral artery, and in the presence of C1 esterase inhibitor deficiency. This phenomenon is usually self-limited and treatment is supportive, although evidence supports the use of antihistamines, steroids, epinephrine, and complement inhibitors. Due to the severity of angioedema and the potential progression to airway compromise, it is crucial to closely monitor patients receiving tissue plasminogen activator.

Concomitant medication in patients with bradykinin‐mediated angioedema – there's more than ACE inhibitors

“…Plasmin, on the other hand, influences the bradykinin production, resulting in angioedema (Figure 2). 66 There are multiple reports about the potential life‐threatening orolingual manifestation 67–70 . A study from the UK reported an 8% incidence of this side effect, ranging from 5 to 189 min after initiation of TPA.…”

“…66 There are multiple reports about the potential life-threatening orolingual manifestation. [67][68][69][70] A study from the UK reported an 8% incidence of this side effect, ranging from 5 to 189 min after initiation of TPA. Other authors reported slightly smaller incidences.…”

Medikamente als Auslöser Bradykinin‐vermittelter Angioödeme – mehr als ACE‐Hemmer

“…Plasmin wiederum beeinflusst die Bradykinin‐Produktion, was zur Angioödem‐Entstehung führen kann (Abbildung 2). 65 Es gibt mehrere Berichte über die potenziell lebensbedrohliche orolinguale Manifestation 66–69 . In einer Studie aus dem Vereinigten Königreich wurde über eine Häufigkeit dieser Nebenwirkung von 8 % berichtet, die zwischen 5 und 189 Minuten nach Beginn der TPA‐Behandlung lag.…”

“…65 Es gibt mehrere Berichte über die potenziell lebensbedrohliche orolinguale Manifestation. [66][67][68][69] In einer Studie aus dem Vereinigten Königreich wurde über eine Häufigkeit dieser Nebenwirkung von 8 % berichtet, die zwischen 5 und 189 Minuten nach Beginn der TPA-Behandlung lag. Andere Autoren berichteten über etwas geringere Inzidenzen.…”

Alteplase associated Orolingual angioedema: A case report and literature review

“…[1] However, in addition to intracranial hemorrhage, Orolingual angioedema (OA) is a rare but potentially life-threatening complication is increasing. [2] OA presents as acute swelling of the tongue, lips, or face and can be life-threatening because it increases the risk of upper airway obstruction. [3] However, the mechanisms underlying RT-PA-induced OA remain unclear.…”