• Jennifer E Fugate, Ejaaz A Kalimullah, and Eelco F M Wijdicks.
• Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. fugate.jennifer@mayo.edu
• Neurocrit Care. 2012 Jun 1;16(3):440-3.

BackgroundAngioedema 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.MethodsCase report.ResultsA 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.ConclusionsOrolingual 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.

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