Orolingual angioedema after treatment of acute ischaemic stroke with alteplase is observed in 5.1% of treated patients.2
Two main risk factors are well known: concomitant ACE inhibitor treatment (RR 13.6) and early MRI evidence of an acute middle cerebral artery ischaemic stroke (RR 6.4).3
Other risk factors are suspected, such as concomitant blocker treatment.1
In this case, the patient was not on any medical treatment, however CT scanning detected early evidence of middle cerebral artery stroke confirmed by the MRI-DWI. The hypothesis about the pathophysiology of OAA suggests simultaneous activation of the complement system and kinin cascasdes by plasmin, produced by alteplase-induced cleavage of plasminogen.2
The direct activation of the complement cascade causes histamine liberation and mast cell degranulation4
followed by a raised bradykinin level (due to the kinin cascade).5
The combination of these two biological pathways leads to significant vasodilatation. ACE inhibitors are associated with more severe OAA because they may induce inhibition of plasma kinases which are responsible for bradykinin degradation. The next day, our patient's blood test revealed disseminated intravascular coagulation (DIC). The literature does not mention any effects following alteplase infusion but the 14th edition of Meyler's Side Effects of Drugs
reports possible DIC with fibrinolytics and specially urokinase. The pathophysiology is unknown but involvement of a urinary thromboplastin is suspected. OAA and DIC are rare but potentially life-threatening complications of thrombolysis requiring control of clinical and biological signs with immediate initiation of specific treatment.
- Orolingual acute angioedema (OAA) after treatment of acute ischaemic stroke with alteplase is observed in around 5% of treated patients.
- The pathophysiology of OAA suggests simultaneous activation of the complement system and kinin cascasdes by plasmin, produced by alteplase-induced cleavage of plasminogen.
- Angiotensin converting enzyme inhibitors are associated with more severe OAA.