Orolingual angioedema during thrombolysis in acute ischemic stroke: A case report

Application of multidisciplinary in situ simulation training in the treatment of acute ischemic stroke: a quality improvement project

BACKGROUND

Ischemic stroke refers to a disorder in the blood supply to a local area of brain tissue for various reasons and is characterized by high morbidity, mortality, and disability. Early reperfusion of brain tissue at risk of injury is crucial for the treatment of acute ischemic stroke. The purpose of this study was to evaluate comfort levels in managing acute stroke patients with hypoxemia who required endotracheal intubation after multidisciplinary in situ simulation training and to shorten the door-to-image time.

METHODS

This quality improvement project utilized a comprehensive multidisciplinary in situ simulation exercise. A total of 53 participants completed the two-day in situ simulation training. The main outcome was the self-reported comfort levels of participants in managing acute stroke patients with hypoxemia requiring endotracheal intubation before and after simulation training. A 5-point Likert scale was used to measure participant comfort. A paired-sample t-test was used to compare the mean self-reported comfort scores of participants, as well as the endotracheal intubation time and door-to-image time on the first and second days of in situ simulation training. The door-to-image time before and after the training was also recorded.

RESULTS

The findings indicated that in situ simulation training could enhance participant comfort when managing acute stroke patients with hypoxemia who required endotracheal intubation and shorten door-to-image time. For the emergency management of hypoxemia or tracheal intubation, the mean post-training self-reported comfort score was significantly higher than the mean pre-training comfort score (hypoxemia: 4.53±0.64 vs. 3.62±0.69, t= -11.046, P<0.001; tracheal intubation: 3.98±0.72 vs. 3.43±0.72, t= -6.940, P<0.001). We also observed a decrease in the tracheal intubation and door-to-image time and a decreasing trend in the door-to-image time, which continued after the training.

CONCLUSION

Our study demonstrates that the implementation of in situ simulation training in a clinical environment with a multidisciplinary approach may improve the ability and confidence of stroke team members, optimize the first-aid process, and effectively shorten the door-to-image time of stroke patients with emergency complications.

Neurologic and Psychiatric Manifestations of Bradykinin-Mediated Angioedema: Old and New Challenges

Neurologic manifestations have been occasionally described in patients with bradykinin-mediated angioedema. The existing literature is currently limited to case series and case reports mainly described in the hereditary forms (HAE) concerning central nervous system (CNS) involvement. On the contrary, very little is known about peripheral and autonomic nervous system manifestations. CNS involvement in HAE may present with symptoms including severe headaches, visual disturbance, seizures, and various focal and generalized deficits. In addition, a stroke-like clinical picture may present in HAE patients. In turn, some drugs used in patients with cardiovascular and neurologic disorders, such as recombinant tissue plasminogen activator (r-tPA) and angiotensin-converting enzyme inhibitors (ACEI), may produce medication-induced angioedema, resulting in a diagnostic challenge. Finally, most patients with HAE have higher levels of psychological distress, anxiety, and depression. With this review, we aimed to provide an organized and detailed analysis of the existing literature on neurologic and psychiatric manifestations of HAE to shed light on these potentially invalidating symptoms and lay the foundation for further personalized diagnostic pathways for patients affected by this protean disease.

Alteplase associated Orolingual angioedema: A case report and literature review

OBJECTIVE

Orolingual angioedema (OA) is a rare but life-threatening complication of intravenous thrombolysis using alteplase. Angioedema can be caused by almost any medication. Administration of recombinant tissue plasminogen activator causes atypical angioedema. This study aimed to investigate factors related to and treatment of OA after thrombolysis with alteplase.

CASE REPORT

We describe the case of a 53-year-old man with a history of hypertension managed with enalapril, who presented with ischemic cerebrovascular stroke. Intravenous alteplase was administered, and within 54 minutes, the patient developed severe orolingual edema requiring emergent intubation. Subsequent imaging revealed an acute-to-subacute infarct in the left occipital lobe of the posterior cerebral artery.

RESULTS

The most common factor for increased risk of OA after recombinant tissue plasminogen activator was concomitant use of angiotensin-converting enzyme inhibitors (ACEI).

CONCLUSION

Before intravenous thrombolytic therapy, patients should be asked if they have a history of allergies, are currently using ACEI, and try to avoid using ACEI antihypertensive drugs before and after thrombolytic therapy.