A 78-year-old man presented to the emergency department with a complaint of weakness on the left side. The weakness had developed 90 minutes earlier and he had no history of using any angiotensin-converting-enzyme (ACE) inhibitors.
The patient was diagnosed with an ischemic stroke in the right middle cerebral artery territory. Treatment was initiated with intravenous tissue plasminogen activator (t-PA). However, a few minutes after the treatment was initiated, the patient developed a swelling on the left side of the tongue. The treatment was stopped. Although, despite stopping the treatment, the swelling continued to progress.
There were no complaints of shortness of breath and pain, with no evidence of airway compromise. The presenting symptoms were consistent with the diagnosis of orolingual angioedema, which is common, known adverse effect of t-PA.
Orolingual angioedema
Orolingual angioedema is a potential adverse effect of t-PA that causes the development asymmetric swellings that can first develop contralateral to the ischemic lesion. It often occurs in patients who have had a history of stroke involving the insula or in patients who have received treatment with an ACE inhibitor. The mechanism of action of orlingual angioedema, however, is not clear.
Treatment was initiated without advanced airway management with glucocorticoids and antihistamines. The swelling of the tongue abated. However, 3 months after presentation, at the follow-up visit, some neurologic deficits that resulted from the stroke remained.
References
Leal Rato, M., & Carvalho Dias, M. (2020). Angioedema after t-PA Infusion. New England Journal of Medicine, 382(25), 2449-2449.
