May 13 Highlights

Abstract

Hill et al. identified an increased risk of hemi-prolingual angioedema after tissue plasminogen activator treatment of acute ischemic stroke associated with angiotensin-converting enzyme inhibitor use and infarction of the frontal and insular cortex. The reaction was usually clinically mild. See page 1525 Thrombolysis—a therapy of proven benefit for stroke—has defined risks, notably a 6% cerebral hemorrhage rate.1 Allergic reactions are rare, but an intriguing syndrome of hemi-orolingual angioedema can occasionally occur contralateral to the treated stroke.2 In the largest case series to date, the Calgary stroke team collected nine patients who experienced hemi-orolingual angioedema after receiving tissue plasminogen activator (t-PA) for stroke for >5 years.3 The team carefully examined 176 consecutively treated stroke patients to find these nine cases. The 5% incidence of hemi-orolingual angioedema in this study is remarkable and is hard to explain; other stroke programs with equal or larger numbers have not seen angioedema as often. Indeed, after many hundreds of t-PA doses administered personally, I have seen it only once, despite looking for it. The mechanism proposed in the article, involving bradykinin metabolism, is plausible and suggests a way to treat the complication. The statistical analysis of Hill et al. provides credence that early ischemic changes (EIC) seen on acute CT brain scans may have related to the incidence of the hemi-orolingual angioedema, although their patient numbers are …