Severe Orolingual and Laryngeal Angioedema after Thrombolysis with Alteplase: Angiotensin II Receptor Blockers Should Not Be Underestimated

We have presented the case of a patient with severe and life-threatening nonimmunologic angioedema secondary to a combination of IV alteplase and valsartan. We emphasize the importance of being aware of this potentially severe complication in patients with ischaemic stroke treated with an rt-PA and in patients on treatment with ACEi and ARB. Alteplase and tenecteplase are recombinant tPA, with a potential risk of producing angioedema. There are no solid treatment recommendations for angioedema caused by rt-PA. Still, an early treatment with icatibant seems to be a consistent option in a bradykinin-mediated angioedema independent of the pathway responsible for bradykinin formation. Specific and revised protocols to manage this solitary angioedema based on severity are crucial and urgent. Finding an alternative IV thrombolytic treatment to improve the patients' safety should become an objective of research.