1
|
Tolu-Akinnawo O, Ogwu OI, Nnamani I, Talabi T. Ipsilateral Orolingual Angioedema Following Alteplase Administration for the Treatment of Suspected Acute Ischemic Stroke. Cureus 2023; 15:e38714. [PMID: 37168409 PMCID: PMC10166123 DOI: 10.7759/cureus.38714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 05/13/2023] Open
Abstract
Intravenous tissue plasminogen activator (tPA) remains the standard of treatment for patients presenting with acute ischemic stroke within the treatment window. In most patients, this often leads to an effective and life-prolonging intervention in the acute setting. This is, however, not without complications, which sometimes could be potentially fatal. Hemorrhagic complications, such as hemorrhagic conversion and bleeding, are the most discussed; however, facial angioedema has also been reported. We present a case of a 72-year-old African American male who developed right-sided ipsilateral orolingual angioedema 20 minutes after starting a tPA infusion. He was subsequently managed with antihistamine medications and steroids with interval resolution of symptoms. This case highlights the need for close monitoring while on tPA infusion, early detection, and management of potential facial angioedema complications. It also serves as a template for further studies focusing on preventative strategies for tPA-induced angioedema.
Collapse
Affiliation(s)
| | - Oghanim I Ogwu
- Internal Medicine, Meharry Medical College, Nashville, USA
| | - Ikenna Nnamani
- Internal Medicine, Meharry Medical College, Nashville, USA
| | - Taiwo Talabi
- Internal Medicine, Meharry Medical College, Nashville, USA
| |
Collapse
|
2
|
Abstract
Stroke is a leading cause of morbidity and mortality and a major cause of long-term disability. Management of acute ischemic stroke in the first hours is critical to patient outcomes. This review provides an overview of acute ischemic stroke management, with a focus on the golden hour. Additional topics discussed include prehospital considerations and initial evaluation of the patient with history, examination, and imaging as well as treatment options, including thrombolysis and endovascular therapy.
Collapse
Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA; Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, Yale New Haven Hospital, New Haven, CT, USA.
| |
Collapse
|
3
|
Duymun S, Reddy V, Bentley E, Bose-Kolanu A. Tissue Plasminogen Activator-Induced Angioedema Involving a Posterior Cerebral Artery Infarct: A Case Presentation. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e927137. [PMID: 33441533 PMCID: PMC7811978 DOI: 10.12659/ajcr.927137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patient: Female, 84-year-old Final Diagnosis: Angioedema Symptoms: Angioedema Medication:— Clinical Procedure: — Specialty: Critical Care Medicine • General and Internal Medicine
Collapse
Affiliation(s)
- Shahnaz Duymun
- Department of Medicine, Arnot Ogden Medical Center, Elmira, NY, USA
| | - Vidhya Reddy
- Department of Medicine, Arnot Ogden Medical Center, Elmira, NY, USA
| | - Emma Bentley
- Department of Medicine, Arnot Ogden Medical Center, Elmira, NY, USA
| | | |
Collapse
|
4
|
Osoba MY, Schneider AL, Alexiev B, Matsuoka AJ. Recurrent macroglossia requiring tracheostomy after haemorrhagic basal ganglia stroke. BMJ Case Rep 2021; 14:14/1/e238775. [PMID: 33431468 PMCID: PMC7802688 DOI: 10.1136/bcr-2020-238775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
A 50-year-old African American woman with hypertension, congestive heart failure, chronic kidney disease and prior cerebral vascular accident was transferred from an outside hospital after being found unresponsive and subsequently intubated for severe orolingual swelling. Imaging showed left thalamic haemorrhagic stroke, and the lingual swelling was clinically concerning for angio-oedema, with which a lingual biopsy was consistent. Work-up was negative for hereditary or acquired angio-oedema, and imaging was negative for structural causes. Of note, the patient had an episode of severe orolingual swelling 3 months prior to this presentation after suffering left thalamic haemorrhage which self-resolved after approximately 2 months. In both episodes lingual swelling predated receipt of tissue plasminogen activator and she had discontinued ACE inhibitor therapy since her first episode of tongue swelling. Despite medical and supportive management, tongue swelling progressed during admission and the decision was made to allow the patient's tongue swelling to self-resolve.
Collapse
Affiliation(s)
- Muyinat Y Osoba
- Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander L Schneider
- Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Borislav Alexiev
- Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Akihiro J Matsuoka
- Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA,Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois, USA,Hugh Knowles Center for Hearing Research, Northwestern University, Evanston, Illinois, USA
| |
Collapse
|
5
|
Orolingual Angioedema After Tissue Plasminogen Activator Administration in Patients Taking Angiotensin-Converting Enzyme Inhibitors. Adv Emerg Nurs J 2019; 41:204-214. [PMID: 31356244 DOI: 10.1097/tme.0000000000000250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Orolingual angioedema is a rare adverse effect (1%-5%) of tissue plasminogen activator (tPA) that can lead to significant morbidity in patients with acute ischemic stroke. It is thought that increased levels of bradykinin and histamine resulting from tPA administration can result in angioedema. Angiotensin-converting enzyme (ACE) inhibitors can also lead to increased levels of bradykinin and appear to be a risk factor for tPA-associated angioedema. A literature review was conducted to examine previous cases of orolingual angioedema associated with tPA administration in patients also taking ACE inhibitors to better understand the relationship between ACE inhibitors and tPA-induced angioedema. Over a 20-year period, 27 patients who experienced angioedema with tPA while on ACE inhibitor therapy were identified. In this patient population, the onset of angioedema symptoms appeared as soon as 15 min after the tPA bolus and as late as 2 hr after the tPA infusion. Most patients required a combination of supportive medications such as corticosteroids (81.5%), antihistamines (74%), and epinephrine (18.5%) for the management of angioedema. Severe presentations of orolingual angioedema resulted in intubation for airway protection (26%). Symptom resolution ranged from shortly after the administration of supportive medications to 72 hr after symptom onset. Orolingual angioedema after tPA administration has the potential to cause significant morbidity, indicating patients should be monitored closely for a few hours after administration for the development of airway compromise. ACE inhibitors should not be the preferred antihypertensive agents for patients who require blood pressure lowering prior to tPA administration.
Collapse
|
6
|
Harris D, Harter D. A Case Report of Unilateral Orolingual Angioedema Secondary to Alteplase Administration. Cureus 2018; 10:e2869. [PMID: 30148021 PMCID: PMC6107327 DOI: 10.7759/cureus.2869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Emergency physicians should be aware of adverse drug reactions prior to administering medication. Alteplase, or tissue plasminogen activator (tPA), is a common medication in the emergency department, whether it is being used for a stroke or pulmonary embolus. Angioedema can be caused by almost any medication. tPA administration can cause an atypical form of angioedema. The following case was one of unilateral orolingual angioedema associated with tPA administration in the emergency department in a stroke patient. The mechanism of tPA-induced angioedema is poorly understood. Angioedema can be treated with stopping the infusion of medication, Benadryl® (Johnson & Johnson Consumer, Inc., Fort Washington, PA), histamine antagonists, steroids, and epinephrine. Angioedema is a life-threatening event in certain situations, and emergency medicine providers would do well knowing how to approach these cases.
Collapse
Affiliation(s)
- Dustin Harris
- Emergency Department, The University of Chicago Medicine, Chicago, USA
| | - David Harter
- Emergency Department, The University of Chicago Medicine, Chicago, USA
| |
Collapse
|
7
|
Brown E, Campana C, Zimmerman J, Brooks S. Icatibant for the treatment of orolingual angioedema following the administration of tissue plasminogen activator. Am J Emerg Med 2018; 36:1125.e1-1125.e2. [DOI: 10.1016/j.ajem.2018.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/07/2018] [Accepted: 03/10/2018] [Indexed: 10/17/2022] Open
|
8
|
Guilarte M, Sala-Cunill A, Luengo O, Labrador-Horrillo M, Cardona V. The Mast Cell, Contact, and Coagulation System Connection in Anaphylaxis. Front Immunol 2017; 8:846. [PMID: 28798744 PMCID: PMC5526842 DOI: 10.3389/fimmu.2017.00846] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/05/2017] [Indexed: 11/13/2022] Open
Abstract
Anaphylaxis is the most severe form of allergic reaction, resulting from the effect of mediators and chemotactic substances released by activated cells. Mast cells and basophils are considered key players in IgE-mediated human anaphylaxis. Beyond IgE-mediated activation of mast cells/basophils, further mechanisms are involved in the occurrence of anaphylaxis. New insights into the potential relevance of pathways other than mast cell and basophil degranulation have been unraveled, such as the activation of the contact and the coagulation systems. Mast cell heparin released upon activation provides negatively charged surfaces for factor XII (FXII) binding and auto-activation. Activated FXII, the initiating serine protease in both the contact and the intrinsic coagulation system, activates factor XI and prekallikrein, respectively. FXII-mediated bradykinin (BK) formation has been proven in the human plasma of anaphylactic patients as well as in experimental models of anaphylaxis. Moreover, the severity of anaphylaxis is correlated with the increase in plasma heparin, BK formation and the intensity of contact system activation. FXII also activates plasminogen in the fibrinolysis system. Mast cell tryptase has been shown to participate in fibrinolysis through plasmin activation and by facilitating the degradation of fibrinogen. Some usual clinical manifestations in anaphylaxis, such as angioedema or hypotension, or other less common, such as metrorrhagia, may be explained by the direct effect of the activation of the coagulation and contact system driven by mast cell mediators.
Collapse
Affiliation(s)
- Mar Guilarte
- Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,VHIR Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Anna Sala-Cunill
- Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,VHIR Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Olga Luengo
- Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,VHIR Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Moisés Labrador-Horrillo
- Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,VHIR Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Victoria Cardona
- Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,VHIR Institut de Recerca Vall d'Hebron, Barcelona, Spain
| |
Collapse
|
9
|
Hofman Z, de Maat S, Hack CE, Maas C. Bradykinin: Inflammatory Product of the Coagulation System. Clin Rev Allergy Immunol 2017; 51:152-61. [PMID: 27122021 PMCID: PMC5025506 DOI: 10.1007/s12016-016-8540-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Episodic and recurrent local cutaneous or mucosal swelling are key features of angioedema. The vasoactive agents histamine and bradykinin are highly implicated as mediators of these swelling attacks. It is challenging to assess the contribution of bradykinin to the clinical expression of angioedema, as accurate biomarkers for the generation of this vasoactive peptide are still lacking. In this review, we will describe the mechanisms that are responsible for bradykinin production in hereditary angioedema (HAE) and the central role that the coagulation factor XII (FXII) plays in it. Evidently, several plasma parameters of coagulation change during attacks of HAE and may prove valuable biomarkers for disease activity. We propose that these changes are secondary to vascular leakage, rather than a direct consequence of FXII activation. Furthermore, biomarkers for fibrinolytic system activation (i.e. plasminogen activation) also change during attacks of HAE. These changes may reflect triggering of the bradykinin-forming mechanisms by plasmin. Finally, multiple lines of evidence suggest that neutrophil activation and mast-cell activation are functionally linked to bradykinin production. We put forward the paradigm that FXII functions as a ‘sensor molecule’ to detect conditions that require bradykinin release via crosstalk with cell-derived enzymes. Understanding the mechanisms that drive bradykinin generation may help to identify angioedema patients that have bradykinin-mediated disease and could benefit from a targeted treatment.
Collapse
Affiliation(s)
- Zonne Hofman
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven de Maat
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Erik Hack
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Coen Maas
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|
10
|
Wu CC, Chen BS. Key Immune Events of the Pathomechanisms of Early Cardioembolic Stroke: Multi-Database Mining and Systems Biology Approach. Int J Mol Sci 2016; 17:305. [PMID: 26927091 PMCID: PMC4813168 DOI: 10.3390/ijms17030305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/01/2016] [Accepted: 02/17/2016] [Indexed: 01/17/2023] Open
Abstract
While inflammation has generally been regarded as a negative factor in stroke recovery, this viewpoint has recently been challenged by demonstrating that inflammation is a necessary and sufficient factor for regeneration in the zebrafish brain injury model. This close relationship with inflammation suggests that a re-examination of the immune system’s role in strokes is necessary. We used a systems biology approach to investigate the role of immune-related functions via their interactions with other molecular functions in early cardioembolic stroke. Based on protein interaction models and on microarray data from the blood of stroke subjects and healthy controls, networks were constructed to delineate molecular interactions at four early stages (pre-stroke, 3 h, 5 h and 24 h after stroke onset) of cardioembolic stroke. A comparative analysis of functional networks identified interactions of immune-related functions with other molecular functions, including growth factors, neuro/hormone and housekeeping functions. These provide a potential pathomechanism for early stroke pathophysiology. In addition, several potential targets of miRNA and methylation regulations were derived based on basal level changes observed in the core networks and literature. The results provide a more comprehensive understanding of stroke progression mechanisms from an immune perspective and shed light on acute stroke treatments.
Collapse
Affiliation(s)
- Chia-Chou Wu
- Laboratory of Control and Systems Biology, Department of Electrical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan.
| | - Bor-Sen Chen
- Laboratory of Control and Systems Biology, Department of Electrical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan.
| |
Collapse
|