Orolingual angioedema treated with Icatibant post-thrombolysis for ischaemic stroke

Abstract

•Orolingual angioedema is a rare side effect of thrombolysis.•Angioedema is uniquely observed as being ipsilateral to the weakness.•Icatibant, a bradykinin inhibitor, was successfully used to treat the angioedema. An 88-year-old woman presented with sudden onset right sided facial droop and right sided hemiplegia. The National Institutes of Health Stroke Score was 5 and her presentation to hospital was within four and a half hours of symptom onset. She was treated with intravenous alteplase. One hour post alteplase she developed unilateral right sided lip and tongue swelling consistent with orolingual angioedema (Fig. 1). The angioedema occurred without stridor or notable airway obstruction. The swelling was ipsilateral to the weakness associated with ischaemic stroke. There was no previous episode of angioedema. The patient was on an angiotensin converting enzyme inhibitor (ACE-inhibitor), Ramipril, for hypertension prior to the stroke. Post-thrombolysis angioedema is rare with an incidence of 1–5%, and an association with pre-stroke ACE-inhibitor use [[1]Lin S.Y. et al.Orolingual angioedema after alteplase therapy of acute ischaemic stroke: incidence and risk of prior angiotensin converting enzyme inhibitor use.Eur J Neurol. 2014; 21: 1285-1291Crossref PubMed Scopus (29) Google Scholar]. Airway compromise is the major concern. Icatibant, a selective and specific antagonist of bradykinin B2 receptors, was administrated with rapid resolution of angioedema over the following hour (Fig. 2). Magnetic response imaging (MRI) revealed an acute ischaemic stroke, characterised as a left lentiform nucleus infarct. Dr Patrick Salvaris has no competing interests. Dr Joshua Laing has no competing interests. Download .xml (.0 MB) Help with xml files Supplementary data