Orolingual angioedema as a complication of systemic thrombolytic therapy with recombinant tissue plasminogen activator

Orolingual angioedema is a rare, but extremely dangerous complication of systemic thrombolytic therapy with recombinant tissue plasminogen activator, the incidence of which reaches 2.2-5.1 %. Orolingual angioedema is a life-threatening condition, as it can lead to airway obstruction and asphyxia. An analysis of a clinical case of orolingual angioedema as a complication of systemic thrombolytic therapy using a recombinant tissue plasminogen activator is presented, risk factors for its development and treatment methods are presented. Orolingual angioedema is a rare life-threatening complication of systemic thrombolytic therapy with recombinant tissue plasminogen activator. It is necessary to assess the severity of edema every 30-60 minutes after systemic thrombolytic therapy in order not to miss the moment of escalation of the process. For the treatment of orolingual angioedema, antihistamines, glucocorticosteroids and adrenaline are used, in case of progressive edema and impaired airway patency, emergency tracheal intubation is performed, followed by artificial ventilation of the lungs.

1. 1 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587. PMID: 7477192 https://doi.org/10.1056/NEJM199512143332401

2. 2 Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329. PMID: 18815396 https://doi.org/10.1056/NEJMoa0804656

3. 3 Pollack CV Jr, Reilly PA, van Ryn J, Eikelboom JW, Glund S, Bernstein RA, et al. Idarucizumab for Dabigatran Reversal - Full Cohort Analysis. N Engl J Med. 2017;377(5):431-441. PMID: 28693366 https://doi.org/10.1056/NEJMoa1707278

4. 4 Protocol of reperfusion therapy of acute ischemic stroke. Moscow, 2019. (In Russ). URL: https://rehabrus.ru/Docs/2020/protokol_14_12_18_isprav.pdf?ysclid=l1ue8f629g

5. 5 Seet RC, Rabinstein AA. Symptomatic intracranial hemorrhage following intravenous thrombolysis for acute ischemic stroke: a critical review of case definitions. Cerebrovasc Dis. 2012;34(2):106–114. PMID: 22868870 https://doi.org/10.1159/000339675

6. 6 Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, et al. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2017;48(12):e343-e361. PMID: 29097489 https://doi.org/10.1161/STR.0000000000000152

7. 7 Myslimi F, Caparros F, Dequatre-Ponchelle N, Moulin S, Gautier S, Girardie P, et al. Orolingual Angioedema During or After Thrombolysis for Cerebral Ischemia. Stroke. 2016;47(7):1825-1830. https://doi.org/10.1161/STROKEAHA.116.013334

8. 8 Hill MD, Barber PA, Takahashi J, Demchuk AM, Feasby TE, Buchan AM. Anaphylactoid reactions and angioedema during alteplase treatment of acute ischemic stroke. CMAJ. 2000;162(9):1281-1284. PMID: 10813008

9. 9 Rathbun KM. Angioedema after thrombolysis with tissue plasminogen activator: an airway emergency. Oxf Med Case Reports. 2019;2019(1):omy112. PMID: 30697429 https://doi.org/10.1093/omcr/omy112 eCollection 2019 Jan.

10. 10 Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e99. PMID: 29367334 https://doi.org/10.1161/STR.0000000000000158

11. 11 Hill MD, Lye T, Moss H, Barber PA, Demchuk AM, Newcommon NJ, et al. Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. Neurology. 2003;60(9):1525–1527. PMID: 12743244 https://doi.org/10.1212/01.wnl.0000058840.66596.1a

12. 12 Engelter ST, Fluri F, Buitrago-Téllez C, Marsch S, Steck AJ, Rüegg S, et al. Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke. J Neurol. 2005;252(10):1167–1170. PMID: 16184341 https://doi.org/10.1007/s00415-005-0789-9

13. 13 Werner R, Keller M, Woehrle JC. Facial angioedema and stroke. Cerebrovasc Dis. 2014;38(2):101–106. PMID: 25277776 https://doi.org/10.1159/000365205

14. 14 Wallon D, Girardie P, Bombois S, Lucas C. Angioneurotic orolingual oedema following thrombolysis in acute ischaemic stroke. BMJ Case Rep. 2010;2010:bcr0620103094. PMID: 22791493 https://doi.org/10.1136/bcr.06.2010.3094

15. 15 Papamitsakis NI, Kuyl J, Lutsep HL, Clark WM. Benign angioedema after thrombolysis for acute stroke. J Stroke Cerebrovasc Dis. 2000;9(2):79–81. PMID: 17895201 https://doi.org/10.1053/jscd.2000.0090079

16. 16 Rafii MS, Koenig M, Ziai WC. Orolingual angioedema associated with ACE inhibitor use after rrtPA treatment of acute stroke. Neurology. 2005;65(12):1906. PMID: 16380611 https://doi.org/0.1212/01.wnl.0000190262.59672.4c

17. 17 Fugate JE, Kalimullah EA, Wijdicks EFM. Angioedema after rtPA: what neurointensivists should know. Neurocrit Care. 2012;16(3):440–443. PMID: 22311232 https://doi.org/10.1007/s12028-012-9678-0

18. 18 Wang Y, Sun H, Wang GN, Zhang XM, Zhang JS. Orolingual angioedema during thrombolysis in acute ischemic stroke: A case report. World J Emerg Med. 2022;13(1):71–73. PMID: 35003421 https://doi.org/10.5847/wjem.j.1920-8642.2022.008