Introduction: Tenecteplase (TNK) is increasingly used for acute ischemic stroke due to its single bolus dosing and fibrin specificity. However, orolingual angioedema is a rare but life threatening complication. It is typically bradykinin mediated and may be worsened by ACE inhibitor use. We present a case of severe TNK induced angioedema in a patient with prior TNK tolerance, highlighting the airway challenges it posed.
Description: A 44 year old male with CAD, prior MI, and remote lacunar stroke presented with facial droop, left eye blurry vision, and left sided ataxia (NIHSS 3). Imaging showed ischemia without hemorrhage or LVO. He received IV TNK after informed consent. Within an hour, he developed worsening sore throat, dysphagia, and post tussive emesis. Exam revealed uvular swelling and posterior oropharyngeal erythema without respiratory distress. Concerned for angioedema and aspiration risk, the ICU team consulted anesthesia. First video laryngoscopy showed a grade 1 view, but tube contact with friable mucosa triggered rapid edema and bleeding. Mask ventilation remained possible but increasingly tenuous. 2 further ICU attempts failed. He was emergently transferred to the OR as an airway alert with ENT and trauma on standby. In the OR, multiple advanced techniques (Glidescope, fiberoptic, bougie, rigid laryngoscopy) yielded grade 3–4 views. Ultimately, an attending anesthesiologist intubated him on the fifth attempt using a Glidescope guided by a glottic air bubble. He was sedated, intubated, treated with steroids and hydroxyzine, and extubated on hospital day 4. MRI showed no infarct, consistent with aborted stroke.
Discussion: Angioedema is a rare but fatal complication of fibrinolytics, mediated by bradykinin. TNK can trigger it even without ACE inhibitor use, and prior tolerance does not ensure safety, suggesting immune sensitization or alternate pathways. This case underscores two key airway risks: rapid mucosal swelling worsening intubation, and increased bleeding from impaired hemostasis. Repeated attempts likely worsened edema. Following the ASA Difficult Airway Algorithm, the team escalated early while the patient remained maskable. As TNK use broadens to milder strokes, clinicians must prioritize first-pass success, airway coordination, and early OR transfer to optimize outcomes.
