Abstract
A 75 year-old female transported to hospital by heli-ambulance presented with disturbance of consciousness. She had been treated for hypertension, chronic atrial fibrillation, and chronic heart failure with an angiotensin converting enzyme (ACE) inhibitor (imidapril 10 mg/day). Examination on admission showed roving eye movement and right hemiparesis. NIHSS score was 35. Head magnetic resonance imaging (MRI) showed a fresh infarction in the left middle cerebral artery (MCA) territory. Magnetic resonance angiography showed the left MCA as defective downstream of the M2 portion. She was treated with 0.6 mg/kg intravenous alteplase at 103 minutes after onset. Shortly after recombinant human tissue-type plasminogen activator (rt-PA) thrombolysis, we found lingual swelling and she was intravenously treated with 500 mg of methylprednisolone. Her disturbance of consciousness and right hemiparesis improved (NIHSS score 16), but after 17 hours, her consciousness disturbance worsened again. Head MRI demonstrated a relapse of a brain infarction in the right MCA territory. Lingual angioedema completely disappeared after 36 hours. When a patient taking an ACE inhibitor is treated with intravenous rt-PA, it appears necessary to ascertain any orolingual angioedema, which can be difficult to find when limited to the tongue.
