A rare but life-threatening Emergency: Orolingual angioedema with tenectaplase therapy

Orolingual angioedema is a rare but potentially life-threatening complication of intravenous thrombolytic therapy for acute ischemic stroke (AIS). While it is a well reported side effect of alteplase, reports involving Tenecteplase (TNK) are limited. Risk factors include concurrent use of angiotensin-converting enzyme (ACE) inhibitors and infarction involving the insular or frontal cortex. A 58-year-old woman with history of hypertension on antihypertensive therapy with benazepril presented to the Emergency Department (ED) with acute aphasia and right-sided hemiplegia. Non-contrast head CT excluded hemorrhage, and she was treated with TNK. Shortly after administration, she developed right-sided upper lip and tongue swelling. Orolingual angioedema was promptly identified, and the patient was treated with intravenous methylprednisolone, diphenhydramine, and famotidine. She was monitored in the neurocritical care unit, and her symptoms gradually resolved without the need for intubation. TNK is increasingly being used as a preferred thrombolytic agent for AIS across many stroke centers in the United States. Though angioedema is a well-defined clinical entity and a known complication of alteplase, particularly for patients taking ACE inhibitors, there is limited literature describing its incidence in patients treated with TNK. ED providers should recognize that orolingual angioedema can occur with TNK. The condition, although often mild, can progress rapidly and become life threatening if the airway is compromised. Prompt identification, risk stratification, and early medical intervention are critical to mitigate the risk of life-threatening deterioration and potentially avoid challenging intubations and airway compromise.