Asymmetric Angioneurotic Edema Associated With Thrombolysis for Acute Stroke

Pancioli, Arthur; Brott, Thomas G.; Robertson, Virginia; Miller, Rosie

doi:10.1016/s0196-0644(97)70147-1

Cited by 40 publications

(21 citation statements)

References 6 publications

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“…Such a discrepancy may be explained by brain infarcts causing injury to the autonomic nervous system which enhances the susceptibility to angioedema [3,6]. Such a hypothesis would also explain why angioedema in several patients (but not in ours) was unilateral [3,5]. The observation that both of our patients had early signs of insular infarction corroborates previous findings indicating that ischemic injury of the insular cortex may play a role in the genesis of angioedema [3].…”

Section: Discussionsupporting

confidence: 81%

Life–threatening orolingual angioedema during thrombolysis in acute ischemic stroke

et al. 2005

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Section: Discussionsupporting

confidence: 81%

Life–threatening orolingual angioedema during thrombolysis in acute ischemic stroke

et al. 2005

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“…[17][18][19] Although the previous use of angiotensin-converting enzyme inhibitors is not a contraindication for the administration of rtPA, physicians should be aware of this potential complication. Presumably, medications used to treat angioedema would be indicated to treat a severely affected patient.…”

Section: Strength Of Recommendationmentioning

confidence: 99%

Guidelines for the Early Management of Patients With Ischemic Stroke

Adams¹,

Adams²,

Zoppo³

et al. 2005

Stroke

405

165

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“…Moreover, the equivalent kinin-forming capacity of both forms of rtPA constitutes an experimental argument against the fact that angioedema observed in stroke during fibrinolysis could be attributed to the arginine content of the injectable form, as previously suggested. [1][2][3][4][5][6][7][8] Our in vitro observations suggest that further characterization of the metabolic pathways (protease-antiprotease balance, metallopeptidases) controlling the release and the inactivation of BK and its active metabolite des-Arg 9 -BK in stroke patients who presented an rtPA-related angioedema is warranted. In conclusion, our data strongly suggest that, similar to other acute side effects of ACE inhibitor, such as angioedema, rtPA-associated angioedema seen in stroke patients may also result from BK release.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8] A substantial number of these patients were simultaneously treated with an angiotensin I-converting enzyme (ACE) inhibitor. Angioedema, a local acute, potentially life-threatening inflammatory reaction, has been reported in patients with acute ischemic stroke treated with rtPA with a frequency of 1.9%.…”

mentioning

confidence: 99%

Biochemical Basis of Angioedema Associated With Recombinant Tissue Plasminogen Activator Treatment

Molinaro

Gervais

Adam

2002

Stroke

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Background-Angioedema has been reported during recombinant tissue plasminogen activator (rtPA) treatment of acute ischemic stroke, often with concomitant use of angiotensin I-converting enzyme inhibitor treatment. Angioedema has been partly attributed to the nonapeptide bradykinin (BK), although its precise role has been poorly documented until now. The purposes of this report are 2-fold. First, we sought to define and characterize the in vitro kinin-forming capacity of rtPA when incubated with human plasma at a concentration within the therapeutic concentration range of rtPA attained in blood in vivo during fibrinolysis. Second, we sought to define the mechanism by which rtPA liberates BK from purified human single-chain high-molecular-weight kininogen, a key constituent of the contact system of plasma and the precursor of BK. Summary of Report-When incubated with human plasma, in the presence of an angiotensin I-converting enzyme inhibitor, rtPA generates BK, which is further metabolized to des-Arg 9 -BK. The quantity of kinins generated by rtPA is similar to that observed during the activation of the contact system of plasma with a negatively charged surface, suggesting that it is physiologically relevant. The total amount of des-Arg 9 -BK liberated during the incubation period depends on the aminopeptidase P activity, its main degrading peptidase. Additionally, incubations using purified proteins of the fibrinolytic and the contact system pathways show that the rtPA kinin-forming capacity is mediated by plasmin. Conclusions-We conclude that rtPA used in vitro at a therapeutic concentration has the capacity to generate significant quantities of kinins from human plasma. This kinin-forming activity depends on the activation of the fibrinolytic pathway. These data suggest that angioedema associated with rtPA treatment of ischemic stroke results directly from plasmin-mediated release of BK. Key Words: angioneurotic edema Ⅲ kinins Ⅲ stroke Ⅲ tissue plasminogen activator S erious allergic reactions (anaphylactoid reactions or angioedema) have been observed during thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) (alteplase) used for the treatment of acute ischemic stroke, myocardial infarction, and deep vein thrombosis. 1-8 A substantial number of these patients were simultaneously treated with an angiotensin I-converting enzyme (ACE) inhibitor. Angioedema, a local acute, potentially life-threatening inflammatory reaction, has been reported in patients with acute ischemic stroke treated with rtPA with a frequency of 1.9%. This frequency is higher than that observed in patients treated with an ACE inhibitor for hypertension or heart failure (0.1% to 0.2%). 1,4,9 In these different clinical situations, angioedema has been attributed, at least in part, to bradykinin (BK).BK is the prototype of a family of powerful vasodilatory peptides, the kinins. BK is released from high-molecularweight kininogen (HK) when hydrolyzed by plasma kallikrein. This hydrolysis occurs, at least in vitro, when plasm...

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Asymmetric Angioneurotic Edema Associated With Thrombolysis for Acute Stroke

Cited by 40 publications

References 6 publications

Life–threatening orolingual angioedema during thrombolysis in acute ischemic stroke

Life–threatening orolingual angioedema during thrombolysis in acute ischemic stroke

Guidelines for the Early Management of Patients With Ischemic Stroke

Biochemical Basis of Angioedema Associated With Recombinant Tissue Plasminogen Activator Treatment

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