In Rare Cases, Stroke Treatment Can Trigger Life-threatening Angioedema, Case Report Shows

Activase (alteplase), a common treatment for stroke, may trigger angioedema of the mouth and tongue that can lead to a life-threatening situation if not treated promptly, a case report shows.

The study, “Angioedema: A Life-threatening Complication of Tissue Plasminogen Activator,” was published in the journal Cureus.

It describes the case of a 78-year-old woman who was hospitalized after complaining of weakness and a loss of sensation on her right side, as well as facial droop and an inability to speak normally.

A blood analysis was normal, and no alterations were detected in a CT scan of her head, leading doctors to suspect acute ischemic stroke on her left side.

Doctors administered Activase (alteplase), a type of tissue plasminogen activator (tPA) used to break down blood clots in acute ischemic stroke patients.

However, three hours later, the woman began complaining of dry mouth. She also experienced progressively worsening swelling of the tongue, which initially affected the right side and then spread to the left.

Doctors suspected the cause of the symptoms was an allergic reaction and stopped Activase treatment. The patient then received intravenous Solu-Medrol (methylprednisolone) and diphenhydramine, corticosteroid and antihistaminic medications that suppress the immune system.

But the woman’s condition continued to worsen, and she required intubation for breathing assistance because her tongue blocked her airways. Mechanical ventilation was removed after three days of treatment with intravenous steroids.

While treatment with Activase and other tissue plasminogen activators are effective in treating ischemic stroke, they are known to cause angioedema in some patients. This can be life-threatening if it affects the airways and is not treated in a timely manner.

“Orolingual angioedema [angioedema of the mouth and tongue] is a life-threatening complication of the treatment of ischemic stroke with tissue plasminogen activator (tPA) with a reported incidence of 1-5%,” researchers noted.

While angioedema is usually not life-threatening and can be managed with antihistamines and steroids, its rapid progression while compromising respiratory airways “needs emergent intubation to protect and maintain the airway,” they added.

“A physician treating acute ischemic stroke with alteplase [Activase] should be aware” of this potential complication, they said. “Routine inspection of the tongue and oropharynx” should be performed every 30-45 minutes after treatment initiation.