Ischemic Stroke Complicated by Tissue Plasminogen Activator (tPA)-Induced Angioedema Requiring Nasotracheal Intubation

Angioedema is the potentially life-threatening phenomenon of localized or generalized swelling from fluid extravasation into interstitium -a process characterized by rapid onset over minutes or hours. Although generally self-limiting, its association with anaphylaxis and propensity to affect the face, mouth and throat makes the need for rapid recognition and diagnosis imperative s as to prevent airway compromise and possible death. We present the case of a 60-year-old male who developed orolingual angioedema with severe airway compromise shortly after receiving intravenous tPA infusion for the treatment of acute ischemic stroke.60-yearold male being treated for hypertension and hyperlipidemia, last known well about an hour ago presenting to the hospital for acute onset left lower extremity weakness. Initial vitals were all within normal limits except for elevated blood pressure. Physical examination confirmed left-side hemiplegia, left facial droop, and altered mental status with an NIH Scale/score of 24. Blood work including urine drug screen were normal. Computed tomography scan of the head without contrast was negative for any acute intracranial abnormality, including hemorrhage, mass effect, midline shift, or hydrocephalus. He was treated with weight-based (0.9 mg/kg) infusion of 90 mg intravenous alteplase. Two hours post infusion, the patient was noted to be in respiratory distress due to progressive airway obstruction from severe orolingual angioedema. Multiple attempts at orotracheal intubation was unsuccessful. The patient was ultimately intubated via a nasotracheal approach via the left nares and admitted to the ICU for further management. He was treated with methylprednisolone 60mg q12 and intravenous diphenhydramine 50mg q6 were administered. Brain MRI later revealed a large ischemic infarct throughout the right frontal lobe, extending to the right parietal lobe and involving the right basal ganglia. Bleeding including intracranial hemorrhage are commonly associated complication of tPA infusion, angioedema is a rare but potentially fatal complication. This is especially common in individuals taking Angiotensin Converting Enzyme inhibitors (ACEi) with an about 7-fold increased. Hence all physicians who administer tPA must be aware of this risk especially in individuals on ACEi. Swift recognition of the signs and symptoms before airway compromise is imperative. Furthermore, nasotracheal intubation might be a good way of securing airway after failure of orotracheal intubation as opposed to other invasive methods like Cricothyrotomy.

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