the benefits of thrombolysis with tissue plasminogen activator ( tpa ) for acute ischaemic stroke have been demonstrated . however , many patients can not be considered for treatment , often because of late presentation , but sometimes as a result of an absolute or relative contraindication to thrombolysis . these contraindications are numerous and include seizure at onset , rapidly resolving symptoms , known coagulopathy , major surgery within the preceding 21 days , or extracranial haemorrhage within 3 months . some of the less frequently encountered contraindications include recent arterial puncture , or known intracranial arteriovenous malformation or unruptured aneurysm . the purpose of this report is to illustrate the case of a patient with two relative contraindications to thrombolysis , who was nonetheless treated without significant complication . a 45 yr old afro - caribbean woman , with a past medical history of sickle cell ( hbsc ) disease , systemic sarcoidosis , and previous splenectomy , was found to have a large ( 20 mm diameter ) right intracavernous internal carotid aneurysm as an incidental finding on an mri brain scan organised for investigation of headaches . she was electively admitted for a catheter angiogram to evaluate the anatomy of the aneurysm further prior to consideration of intervention . 
 figure  1ct angiogram demonstrating the intracavernous aneurysm measuring 20 mm 
  ct angiogram demonstrating the intracavernous aneurysm measuring 20 mm using a conventional femoral arterial approach , the left ica was catheterised , at which point the patient suddenly became confused and irritable . examination revealed dysarthria and a dense left hemiparesis ( mrc power 0/5 upper and lower limbs ) , visual inattention to the left , with an nihss ( national institutes of health stroke scale ) score of 10 . the catheter study was aborted and an urgent unenhanced ct brain scan did not demonstrate any early ischaemic changes or haemorrhage . a ct angiogram excluded iatrogenic arterial dissection and intracranial proximal arterial occlusion . at this stage it was felt that the likely aetiology was an embolic event related to instrumentation during the angiogram . tissue plasminogen activator ( tpa ) was administered intravenously ( 0.9 mg / kg ) within 60 minutes of symptom onset . during thrombolysis , the patient started to complain of severe right foot pain and then back pain , which was treated with supplementary oxygen , intravenous fluids and pethidine analgesia . blood tests revealed an hbs level of 47% , with an hb of 9.7 g / dl . the haematologists were consulted ; they advised manual exchange transfusion to reduce the sickle load and the risk of further stroke . a femoral vascath was inserted and transfusion was commenced , within 12 hours of thrombolysis . an mri brain scan after 48 hours revealed a subacute right middle cerebral artery ( mca ) territory infarct involving the lateral temporal lobe and posterior frontal lobe with evidence of mild haemorrhagic transformation ( figure  2 ) , which was asymptomatic ( no deterioration in nihss associated with this 0 . further investigations revealed no cardio - embolic source on echocardiography and 24 hours of ecg telemetry . blood tests including treponemal serology , anti - nuclear abs , anti - cardiolipin abs , anti - beta2 glycoprotein 1 abs , thyroid function tests , renal function , liver function , bone profile , cholesterol and glucose all normal . her conventional vascular risk factors aside from her sc disease were limited to a history of smoking and a family history of ischaemic heart disease . her prescribed medications before the acute event were prednisolone , methotrexate , penicillin v , and folate . figure  2mri brain revealing a subacute right mca territory infarct involving the lateral temporal lobe and posterior frontal lobe with evidence of mild haemorrhagic transformation 
  mri brain revealing a subacute right mca territory infarct involving the lateral temporal lobe and posterior frontal lobe with evidence of mild haemorrhagic transformation the patient had further exchange transfusions ( 12 units in total ) which reduced the hbs level to 10.8% and hbc to 10.6% . she was discharged for further rehabilitation with a small improvement to 8 of her nihss score . the decision to thrombolyse this patient was a challenging one , given her known unruptured large aneurysm , and little evidence in the published literature to guide us . we have reviewed the literature on this and on the thrombolysis of patients with sickle cell disease , on pubmed using the search terms  sickle cell  ,  thrombolysis  and  aneurysm  . edwards et al ( 2012 ) published a retrospective study of their experience in 236 patients given tpa over an eleven year period at two academic medical centres . the rates of haemorrhage did not significantly differ between those with or without an unruptured aneurysm . furthermore , none of the patients receiving tpa with an unruptured aneurysm had a symptomatic bleed . this was further substantiated by mittal et al ( 2012 ) who carried out a retrospective analysis of 105 patients treated with tpa and evaluated with intracranial angiography , of whom 10 had an intracranial aneurysm . the size of the largest unruptured aneurysm reported previously in a patient that received tpa is 16 mm . rammos et al ( 2011 ) described a 51 yr old female who presented with a subarachnoid haemorrhage from an acutely ruptured anterior communicating artery aneurysm after receiving tpa for an acute left middle cerebral artery embolism . lagares et al ( 1999 ) reported an acutely ruptured anterior communicating artery aneurysm eight hours after receiving tpa for an acute myocardial infarct . there is very little literature concerning the use of tpa in patients with sickle cell disease . sidani et al ( 2008 ) described a 21 yr old male with hbss who presented with an extensive venous sinus thrombosis that failed to improve 24hrs after receiving automated red blood cell exchange followed by intravenous heparin . there are no reports in the literature of the use of thrombolysis for arterial stroke in sickle cell patients . in summary , this is the first report of the use of thrombolysis for an arterial infarct in a sickle cell patient and in the presence of the largest unruptured aneurysm reported in the literature . on reviewing the literature , it is clear that some relative contra - indications to thrombolysis are not convincingly supported by evidence . randomised trial data is unlikely to be forthcoming in most instances , so reports of treatment without complications may be helpful when faced with these management dilemmas . as thrombolysis becomes more common , there may be an opportunity to build up a registry of such cases as an aid to clinicians faced with these difficult management decisions . this research received no specific grant from any funding agency in the public , commercial , or not - for - profit sectors all contributing authors are listed this research received no specific grant from any funding agency in the public , commercial , or not - for - profit sectors
many patients with acute ischaemic stroke have contraindications to thrombolytic therapy . 
 we describe a 45 yr old afro - caribbean female with hbsc disease whom was electively admitted for a cerebral angiogram to evaluate an intracavernous aneurysm measuring 20 mm in diameter . during the procedure 
 , she suffered a right mca territory ischaemic event with a nihss of 10 . 
 a ct angiogram demonstrated no dissection and no evidence of a major vessel occlusion . 
 tissue plasminogen activator ( tpa ) was administered intravenously within 60 minutes of symptom onset . 
 she had clinical and haematological evidence of a painful sickle cell crisis and required manual exchange transfusion within a few hours of thrombolysis . 
 this is the first reported case of the use of thrombolysis for acute stroke in a sickle cell crisis ; and in the presence of such a large unruptured aneurysm . 
 a registry of unusual thrombolysis cases might help clinicians in cases when there is little evidence to support decision - making .