Tenecteplase-Associated Delayed Orolingual Angioedema in ACE inhibitor-Naive Hypertensive Stroke: A Case Report

Tenecteplase is a modified form of tissue plasminogen activator that has been gaining traction as a thrombolytic option in acute ischemic stroke, largely because it can be given as a single bolus and has a more predictable pharmacokinetic behaviour compared to older agents. Orolingual angioedema, though uncommon, is one of the more serious complications that can arise. Most of what has been reported concerns alteplase, and reports on tenecteplase remain few. A 77-year-old female presented with sudden onset right-sided body weakness and slurred speech. She is diagnosed with hypertension that has not been well controlled on amlodipine alone. Her National Institutes of Health Stroke Scale (NIHSS) was 10. Non-contrast CT head ruled out haemorrhage, and she received tenecteplase within the treatment window and remained stable for the first hour. Around ninety minutes post-infusion, however, she developed tongue and lip swelling without any rash or hemodynamic compromise. Tenecteplase-associated orolingual angioedema can occur in the absence of recognised pharmacological risk factors. Given this, keeping a close eye on these patients well after the initial monitoring period seems worthwhile, and any early signs of airway involvement should be acted on without hesitation. This case adds to the limited experience with tenecteplase-associated angioedema and notably occurred in the absence of recognised predisposing factors.