Select hyperacute complications of ischemic stroke: cerebral edema, hemorrhagic transformation, and orolingual angioedema secondary to intravenous Alteplase

ABSTRACT

Introduction: Remarkable advances have occurred in the management of acute ischemic stroke, especially in regards to reperfusion treatments. With advances in reperfusion treatments come the risk of complications associated with these treatments.

Areas covered: The article focuses on three acute complications that can occur in the setting of acute ischemic stroke: cerebral edema, hemorrhagic transformation, and orolingual angioedema following administration of alteplase, a recombinant tissue plasminogen activator. Predictors of the development of these complications are reviewed. The management of cerebral edema and hemorrhagic transformation is also reviewed in depth including potential new treatments targeting the blood-brain barrier. The article also reviews the management of the rare but potentially fatal complication of orolingual angioedema secondary to alteplase.

Expert commentary: An understanding of the pathophysiology leading to the development of malignant cerebral edema and hemorrhagic transformation allows the clinician to anticipate and properly manage these acute complications. Regardless of a patient’s age or comorbidities, the decision to pursue decompressive hemicraniectomy in patients with malignant cerebral edema should be based on an honest assessment of expected outcome and guided by the patient’s prior wishes regarding an acceptable quality of life.

KEYWORDS:

• Cerebral edema
• hemorrhagic transformation
• orolingual angioedema
• intravenous alteplase
• acute ischemic stroke
• complications

Declaration of interest

J Biller is an Editorial Board member of the stroke section of UpToDate and editor of Stroke and Cerebrovascular Diseases. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.