ORIGINAL ARTICLE Incidence of orolingual angioedema after intravenous thrombolysis for stroke Bruno Censori 1 & T. Partziguian 1 & V. Bonito 1 & M. Sgarzi 1 & R. Riva 1 & D. Alimonti 1 & E. Agazzi 1 & M. Vedovello 1 & B. Frigeni 1 & E. Venturelli 1 & S. La Gioia 1 & V. Barcella 1 & L. Daleffe 2 & L. Longhi 3 & F. Ferri 3 & R. Cosentini 2 & M. R. Rottoli 1 Received: 30 April 2018 /Accepted: 26 July 2018 # Springer-Verlag Italia S.r.l., part of Springer Nature 2018 Abstract Introduction Orolingual angioedema (OA) is a known adverse effect of intravenous (i.v.) alteplase. We analyzed all patients treated with i.v. alteplase for stroke at our hospital since approval of i.v. thrombolysis in Italy in 2004 to assess the incidence of this complication. Patients and results Four hundred thirty-three patients received alteplase for stroke from April 2004 to May 2017. Two women developed OA (0.4%; 95% confidence interval 0.1 to 1.6%). Angioedema was mild in one case and severe in the other, with massive swelling of the lips, tongue, and oropharyngeal mucosa, and oropharyngeal bleeding, requiring intubation. Neither patient used ACE-inhibitors. Discussion The incidence of orolingual angioedema was very low in our series. Although OA is usually mild, anaphylactoid reactions may rarely occur, because of the variable degree of activation of the complement system and kinin cascade caused by alteplase. In such instances, admission to neurointensive care may be required. Specific bradykinin antagonists or drugs that target the kallikrein-kinin system are beginning to be used in the more severe cases. Thus, doctors and nurses caring for acute stroke patients need to be able to recognize and treat this complication. Keywords Stroke . Alteplase . Thrombolysis . Angioedema . Bradykinin Introduction Orolingual angioedema (OA) is a known adverse effect of intravenous (i.v.) alteplase that may present with different degrees of severity from mild lingual edema to massive swelling of the mouth and pharynx, requiring emergent medical therapy and intubation to allow adequate ventila- tion [ 1–3]. We analyzed the patients treated with i.v. alteplase for stroke at our hospital since approval of i.v. thrombolysis in Italy in 2004 to assess the incidence of this complication. Patients and methods All patients treated with i.v. alteplase for stroke since 2004 were prospectively recorded in an electronic database which included age, sex, race, severity of stroke according to the NIHSS, alteplase dose, glucose levels before treatment, and ASPECTS score. Complications of alteplase, including symp- tomatic hemorrhage, death, fibrinogen level after thrombolysis, and orolingual angioedema were recorded as well. The pres- ence of OA was checked with the same time schedule required for neurological surveillance after start of thrombolysis, that is, every 15 min for the first 3 h, than every 30 min for the follow- ing 5 h, than every hour up to 24 h after thrombolysis. Severity of OA, details of treatment, and outcome were extracted from the medical records at the time of hospitalization when OA occurred and were kept in a separate record. * Bruno Censori bcensori@asst-pg23.it 1 USC Neurologia, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy 2 Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy 3 Neurosurgical Intensive Care Unit Department, ASST Papa Giovanni XXIII, Bergamo, Italy Neurological Sciences https://doi.org/10.1007/s10072-018-3512-1