Estimated 1% to 2% of all alteplase treated stroke. Common in patients taking ACE inhibitors. Usually starts near end of alteplase infusion.  If edema limited to anterior tongue and lips, intubation often not necessary. 

If angioedema occurs, stop alteplase and give:

1. Diphenhydramine 50 mg IV
2. Ranitidine 50 mg IV or famotidine 20 mg IV
3. Methylprednisolone 125 mg IV

If there is further increase in angioedema, administer epinephrine (0.1%) 0.3 ml SQ or 0.5 ml racemic epi by nebulizer.  Call anesthesia/alert ED attending.