O r i g i n a l a r t i c l e 3. 4. 5. 6. 7. Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS–MOST): an observational study. Lancet 2007;369:275–82. Adams HP Jr, Adams RJ, Brott T, et al, Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056–83. Semplicini A, Cal`o L. Administering antihypertensive drugs after acute ischemic stroke: timing is everything. Can Med Assoc J 2005;172:625–6. Fiorelli M, Bastianello S, von Kummer R, et al. Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3- month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke 1999;30:2280–4. Abel-Smith B, Mossialos E. Cost containment and health care reform: a study of the European Union. Health Policy 1994;28:89–132. Images in emergency medicine Lingual haematoma: a rare complication of usual warfarin dose A 66-year-old man presented with lingual oedema of purplish colour, with pain and swelling and was admitted to the emergency room. He was taking warfarin at a dose of 5 mg for mitral valve disease as well as a diuretic and digoxin. He had not been exposed to any trauma. On physical examination, no haemorrhagea was observed other than that of lingual haematoma (fig 1). Laboratory examinations showed an international normalised ratio of 50.15, a haemoglobin value of 8.7 g/dl. Nasal oxygen, 5 IU fresh frosen plasma, 2 U erythrocyte suspension and 20 mg vitamin K were given to the patient. Two days later, the lingual haematoma had disappeared. Haemorrhageas caused by warfarin overdose usually appear in the genitourinary, gastrointestinal, retroperitoneal and intracranial areas. In the literature, 10 cases have so far been reported, including sublingual and retropharyngeal haemorrha- gea. This is the first isolated lingual haematoma observed on a normal warfarin dose without overdosing, according to our knowledge, to be reported in the literature. 8. 9. 10. 11. 12. Wiegand N, Luthy R, Vogel B, et al. Intravenous thrombolysis for acute ischaemic stroke in a hospital without a specialised neuro-intensive care unit. Swiss Med Wkly 2004;134:14–17. The NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke 1997;28:2109–18. Brott T, Lu M, Kothari R, Fagan SC, et al. Hypertension and its treatment in the NINDS rt-PA Stroke Trial. Stroke 1998;29:1504–9. Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/ American Stroke Association, Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke 2007;38:1655–711. Audebert HJ, Kukla C, Clarmann von Claranau S, et al. Telemedicine for safe and extended use of thrombolysis in stroke: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria. Stroke 2005;36:287–91. Figure 1 Lingual haematoma caused by usual warfarin dose. Informed consent was obtained for publication of this figure. Correspondence to: Dr F Acar, Kalenderhane M Hızırbey S Karatay Site A No: 1/32, 42050 Karatay-Konya, Turkey; drfacar@selcuk.edu.tr Competing interests: None. Emerg Med J 2008;25:406. doi:10.1136/emj.2007.053314 F Acar, S A Girisgin, B Cander, S Ozdinc Department of Emergency Medicine, Selcuk University Meram Medical School, Konya, Turkey REFERENCE 1. Gonzalez-Garc´ıa R, Schoendorff G, Mu˜noz-Guerra MF, et al. Upper airway obstruction by sublingual hematoma: a complication of anticoagulation therapy with acenocoumarol. Am J Otolaryngol—Head Neck Med Surg 2006;27:129–32. 406 Emerg Med J July 2008 Vol 25 No 7