From the Guidelines
Yes, a patient with facial droop and dysarthria from a lacunar stroke can develop transient perioral swelling that mimics angioedema, though this is not a direct effect of the stroke itself, but rather a potential side effect of treatment with intravenous rtPA, as reported in the guidelines for the early management of patients with acute ischemic stroke 1. This phenomenon is more likely related to orolingual angioedema reactions, which are typically mild, transient, and can occur in patients who receive intravenous rtPA treatment for ischemic stroke, with an estimated frequency of 1.3% to 5.1% of all patients 1. The swelling typically appears on the same side as the facial weakness, is self-limiting, and resolves within hours to days without specific treatment. It's essential to distinguish this from true angioedema, which would require different management, such as empiric treatment with intravenous ranitidine, diphenhydramine, and methylprednisolone 1. No specific medications are needed for stroke-related perioral swelling, but the underlying stroke should be treated according to standard protocols, including the potential use of intravenous rtPA within the 3-hour window from stroke onset, as supported by the SITS-ISTR Registry 1. Clinicians should be aware that this swelling does not represent an allergic reaction and should not delay appropriate stroke management. Key considerations in managing patients with acute ischemic stroke include the severity of deficits, patient age, and the potential for favorable outcomes with treatment, as outlined in the guidelines 1. In particular, patients with mild to moderate strokes (NIHSS score <20) and those under 75 years of age have the greatest potential for an excellent outcome with treatment 1. Overall, the management of patients with acute ischemic stroke requires careful consideration of the potential benefits and risks of treatment, including the risk of orolingual angioedema reactions, to optimize patient outcomes.
From the Research
Clinical Presentation of Lacunar Stroke
- Lacunar stroke can present with various clinical syndromes, including pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis, and dysarthria-clumsy hand syndrome 2.
- Dysarthria is a frequent symptom in cerebral ischemia, and it can be associated with a classic lacunar stroke syndrome in approximately 52.9% of patients 3.
- Facial droop and dysarthria can be symptoms of a lacunar stroke, particularly if the lesion is located in the lower part of the primary motor cortex, middle part of the centrum semiovale, or base of the pons 3.
Transient Swelling around the Mouth
- There is no direct evidence in the provided studies to suggest that transient swelling around the mouth, mimicking angioedema, is a common or well-documented complication of lacunar stroke.
- However, it is possible that swelling or facial weakness could occur due to the effects of a lacunar stroke on the facial nerve or surrounding tissues, as seen in the case report of a pontine stroke presenting as isolated facial nerve palsy 4.
- The exact mechanism and frequency of such swelling are unclear and would require further investigation to determine if it is a direct result of the acute stroke or another underlying condition.
Management and Prognosis of Lacunar Stroke
- Lacunar stroke patients require adequate and rigorous management and follow-up, including antiplatelet drugs, careful blood pressure control, the use of statins, and modification of lifestyle risk factors 2.
- The addition of clopidogrel to aspirin did not significantly reduce the risk of recurrent stroke and did significantly increase the risk of bleeding and death in patients with recent lacunar strokes 5.
- Treatment approaches to lacunar stroke are limited, and there is a need for further research to develop effective therapies that target small vessel disease-related strokes 6.