J Clin Neurol.  2008 Mar;4(1):29-32. 10.3988/jcn.2008.4.1.29.

Life-Threatening Anaphylactoid Reaction in an Acute Ischemic Stroke Patient With Intravenous rt-PA Thrombolysis, Followed by Successful Intra-Arterial Thrombolysis

• Park IS
• Cho AH
• Lee SJ
• Kim JS
• Lee KS
• Kim YI

• KMID: 2287682
• DOI: http://doi.org/10.3988/jcn.2008.4.1.29

Abstract

An anaphylactoid reaction to recombinant tissue plasminogen activator (rt-PA) is an uncommon but fatal complication. A 39-year-old man was admitted within 1 hour of the onset of a right hemispheric stroke. He was not taking any specific medication, including angiotensin-converting enzyme (ACE) inhibitors. A systemic anaphylactoid reaction developed immediately after rt-PA infusion. However, the symptoms were improved after treatment with a steroid and antihistamine. Subsequent intra-arterial thrombolytic therapy resulted in complete recanalization and clinical improvement. To our knowledge, this is the first report of a life-threatening anaphylactoid reaction after rt-PA treatment followed by successful intra-arterial thrombolytic therapy in a patient who had not taken an ACE inhibitor.

Keyword

Recombinant tissue plasminogen activator; Acute ischemic stroke; Anaphylactoid reaction

MeSH Terms

Adult
Humans
Stroke
Thrombolytic Therapy
Tissue Plasminogen Activator
Tissue Plasminogen Activator

Figure

• 

  Figure Sulcal effacement of the right middle cerebral artery (MCA) territory evident on pretreatment CT scans (A, B). Infusing 80,000 U of urokinase into the occluded right MCA (C) resulted in complete recanalization being evident on the final angiogram (D).

Reference

1. Hill MD, Barber PA, Takahashi J, Demchuk AM, Feasby TE, Buchan AM. Anaphylactoid reactions and angioedema during alteplase treatment of acute ischemic stroke. Can Med Assoc J. 2000. 162:1281–1284.

2. Krmpotic KR, Fernandes CM. Anaphylactoid reaction to recombinant tissue plasminogen activator. Eur J Emerg Med. 2007. 14:60–61.

3. Hill MD, Lye T, Moss H, Barber PA, Demchuk AM, Newcommon NJ, et al. Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. Neurology. 2003. 60:1525–1527.

4. Pancioli A, Brott T, Donaldson B, Miller R. Asymmetric angioneurotic edema associated with thrombolysis for acute stroke. Ann Emerg Med. 1997. 30:227–229.

5. Rudolf J, Grond M, Schmülling S, Neveling M, Heiss W. Orolingual angioneurotic edema following therapy of acute ischemic stroke with alteplase. Neurology. 2000. 55:599–600.

6. Engelter ST, Fluri F, Buitrago-Téllez C, Marsch S, Steck AJ, Ruegg S, et al. Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke. J Neurol. 2005. 252:1167–1170.

7. Adams HP Jr, del Zoppo G, Albers MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007. 38:1655–1711.

8. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995. 333:1581–1587.

9. Massel D, Gill JB, Cairns JA. Anaphylactoid reaction during an infusion of recombinant tissue-type plasminogen activator for acute myocardial infarction. Can J Cardiol. 1991. 7:298–302.

10. Cugno M, Cicardi M, Colucci M, Bisiani G, Merlini PA, Spinola A, et al. Non neutralizing antibodies to tissue type plasminogen activator in the serum of acute myocardial infarction patients treated with the recombinant protein. Thromb Haemost. 1996. 76:234–238.

11. Rudolf J, Grond M, Prince WS, Schmülling S, Heiss WD. Evidence of anaphylaxy following alteplase infusion. Stroke. 1999. 30:1142–1143.

12. Bennett WR, Yawn DH, Migliore PJ, Young JB, Pratt CM, Raizner AE, et al. Activation of the complement system by recombinant tissue plasminogen activator. J Am Coll Cardiol. 1987. 10:627–632.

13. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007. 38:967–973.