Angioedema after thrombolytics in CVA

Q: 54 year old male is started on thrombolytics therapy after he presented with stroke like symptoms within three hours. Patient developed swelling of the tongue after few minutes of infusion of thrombolytics. There is a concern for orolingual angioedema. All of the following are the proper actions to follow except?

A) Check home med-list to see if he is on angiotensin converting enzyme inhibitors (ACE-I)
B) Revisit CT scan to see if there is a sign of ischemia in the frontal lobe
C) Perform CT of the tongue to rule out hematoma of the tongue
D) administer corticosteroids and antihistamines 
E) No matter what - continue the thrombolytics 
F) Intubate the patient if there is a sign of stridor



Answer:  E

Orolingual angioedema after the initiation of thrombolytics is not an uncommon scenario. Revisiting history, physical exam and radiological data may help to establish proper diagnosis within minutes. Patients on ACE-I  are on increased risk to develop orolingual angioedema (choice A). Patients who have evidence of ischemia in the frontal lobe on CT scan are more prone to it (Choice B). On physical exam, angioedema is usually present on the contralateral side of the ischemic hemisphere. It may be of importance to rule out hematoma of the tongue secondary to thrombolytics (Choice C). Strong consideration should be given to discontinue the thrombolytics in such circumstances (Choice E is wrong). Airway management in such scenarios are the first priority (Choices D and F).



References:

1. Jauch EC, Saver JL, Adams HP Jr, et al. 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 2013; 44:870. 

2. Hurford R, Rezvani S, Kreimei M, et al. Incidence, predictors and clinical characteristics of orolingual angio-oedema complicating thrombolysis with tissue plasminogen activator for ischaemic stroke. J Neurol Neurosurg Psychiatry 2015; 86:520. 

3. Myslimi F, Caparros F, Dequatre-Ponchelle N, et al. Orolingual Angioedema During or After Thrombolysis for Cerebral Ischemia. Stroke 2016; 47:1825. 

4. Hill MD, Lye T, Moss H, et al. Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. Neurology 2003; 60:1525. 

5.  Chodirker WB. Reactions to alteplase in patients with acute thrombotic stroke. CMAJ 2000; 163:387.