Management of Orolingual Angioedema Associated With IV Alteplase Administration for acute ischemic stroke

  • Maintain airway
    • Endotracheal intubation may not be necessary if edema is limited to anterior tongue and lips.
    • Edema involving larynx, palate, floor of mouth, or oropharynx with rapid progression (within 30 min) poses higher risk of requiring intubation.
    • Awake fiberoptic intubation is optimal. Nasal-tracheal intubation may be required but poses risk of epistaxis post-IV alteplase. Cricothyroidotomy is rarely needed and also problematic after IV alteplase.
  • Discontinue IV alteplase infusion and hold ACEIs
  • Administer IV methylprednisolone 125 mg
  • Administer IV diphenhydramine 50 mg
  • Administer ranitidine 50 mg IV or famotidine 20 mg IV
  • If there is further increase in angioedema, administer epinephrine (0.1%) 0.3 mL subcutaneously or by nebulizer 0.5 mL
  • Icatibant, a selective bradykinin B2 receptor antagonist, 3 mL (30 mg) subcutaneously in abdominal area; additional injection of 30 mg may be administered at intervals of 6 h not to exceed total of 3 injections in 24 h; and plasma-derived C1 esterase inhibitor (20 IU/kg) has been successfully used in hereditary angioedema and ACEI-related angioedema
  • Supportive care

Notes

  • ACEI = angiotensin-converting enzyme inhibitor
  • AIS = acute ischemic stroke
  • IV = intravenous
  • LOE = Level of Evidence.


References

  • 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke, Stroke. 2018 Mar;49(3):e46-e110 doi: 10.1161/STR.0000000000000158