intravenous rtpa remains the only proven treatment for acute ischaemic stroke in the general population . patients with end - stage renal disease ( esrd ) on dialysis have a 510-fold higher incidence of stroke than the general population with an overall incidence rate of 1333 per 1000 patient - years . this may reflect the bleeding diathesis of uraemia   as well as the effects of anticoagulation for vascular access and dialysis circuit patency , the prevalence and degree of hypertension , and the established ethnic variations . patients with esrd have been traditionally excluded from the large prospective randomized controlled trials that form the evidence base for treatment of vascular disease , including stroke , in the general population . renalism   is to potentially restrict access to beneficial therapies in a cohort that would have derived the greatest benefit . in addition , extrapolating outcome data derived from studies in the general population to patients on haemodialysis is not always fruitful . in one of the few adequately powered large prospective randomized controlled trials in haemodialysis ( hd ) , atorvastatin did not reduce the incidence of stroke in stark contrast to studies in the general population . at present , the use of thrombolytic therapy for acute ischaemic stroke in hd patients has not been described . he had a prior diagnosis of progressive chronic kidney disease secondary to obstructive uropathy and recurrent urosepsis , and a hydronephrotic left kidney requiring insertion of a j - j ureteric stent in june 2009 . in addition , he had type 2 diabetes mellitus , ischaemic heart disease ( myocardial infarction march 2009 ) and a diagnosis of hypertension . he did not have a history of cardiac dysrhythmia , a prothrombotic diathesis or cerebrovascular disease . following emergency admission to the intensive care unit with pulmonary oedema , oliguria and a serum creatinine of 10.2 mg / dl ( 899 mol / l ) , he was established on maintenance thrice weekly hd via a right internal jugular tunnelled cuffed central venous catheter ( tesiocath , medcomp , harleysville , pa , usa ) 2.5-months prior to presentation with an acute stroke . he presented to his local emergency department with acute right hemiparesis and aphasia of a 90-min duration . he had undergone routine hd 24-h with no complications prior to presentation . on arrival , his blood pressure ( bp ) was 190/87 mmhg , capillary blood glucose was 86.5 mg / dl ( 4.8 mmol / l ) and his glasgow coma score ( gcs ) was 15/15 . an urgent ct scan of his brain revealed an acute ischaemic stroke affecting the superior parasagittal cortex of the left frontal lobe . clinical examination revealed a mild right facial droop , evidence of a right hemiparesis ( power 3/5 in the upper limb and power 0/5 in the lower limb ) with increased muscle tone in the upper limb , lower limb hyper - reflexia and an upgoing plantar response in the lower limb . laboratory tests at time of presentation there were no absolute contraindications to thrombolysis , and he was eligible for trial enrolment . following informed consent , he underwent randomization and received 54 mg rtpa ( 0.9 mg / kg  weight estimated at 60 kg ) as per trial protocol ( 10% bolus followed by an infusion ) . rtpa ( actilyse , boehringer ingelheim ltd , bracknell , berkshire , uk ) was delivered at 4-h after symptom onset . a repeat ct brain scan was performed 24-h after thrombolysis which showed a small area of haemorrhagic transformation within the original infarct and no other interval change ( figure 1 ) . he remained clinically stable although required sodium valproate ( 600 mg b.d . ) and clobazam ( 5 mg o.d . ) for intermittent left upper limb myoclonus which responded well to therapy . a 24-h holter during the interdialytic period revealed sinus rhythm with a 1-h paroxysm of asymptomatic atrial fibrillation that terminated spontaneously . four days after admission , he was transferred to our specialist renal stroke rehabilitation unit where he was an inpatient for the following month . during this time , power in his upper limb improved to 4/5 proximally and 3/5 distally , and in his lower limb to 4/5 proximally . he was discharged home 5 weeks after his initial admission and remains stable on maintenance hd . single representative axial section through the brain post - thrombolysis . within the parasagittal cortex of the left frontal lobe in the anterior cerebral artery territory is an ischaemic infarct with a small amount of haemorrhagic transformation ( area of increased attenuation marked with the arrow ) . rtpa ( alteplase ) is a glycoprotein that becomes activated on binding to fibrin , converting plasminogen to plasmin and leading to fibrinolysis . when administered within 3-h of symptom onset in the seminal placebo - controlled national institute of neurological disorders and stroke ( ninds ) rtpa study , it resulted in a significantly better neurological outcome at 3 months . analysis of pooled results of six randomized controlled trials of intravenous rtpa showed that the best outcomes occurred in patients treated within 2-h of symptom onset and suggested a benefit extending to 4.5-h . although mortality did not differ between the two groups , 52.4% patients in the rtpa arm recovered with no disability after 90% vs 45.2% in the placebo arm ( p = 0.04 ) . there was , however , a higher rate of symptomatic intracerebral haemorrhage in the rtpa arm ( 2.4% vs 0.2% , p = 0.008 ) in keeping with prior studies . a cochrane systematic review suggested a benefit associated with rtpa up to 6-h from symptom onset , and this is currently under study . use of rtpa is contraindicated in cases where there is a  known haemorrhagic diathesis or severe uncontrolled arterial hypertension ( defined as 185/110 mmhg ) as well as  administration of heparin within the previous 48-h and a thromboplastin time exceeding the upper limit of normal for laboratory. the manufacturer advises caution in  all situations where there is a high risk of haemorrhage . the use of warfarin in hd patients with atrial fibrillation or for maintenance of arteriovenous graft patency will preclude some patients from receiving rtpa despite a study demonstrating a higher incidence of stroke in patients on this therapy . high rates of coronary and peripheral arterial disease and its treatment with percutaneous interventions in esrd lead to a significant proportion of patients on single or dual maintenance antiplatelet therapy . clinicians need to be aware of the high rates of occult gastrointestinal bleeding in hd patients as well as considering uraemia as a state of mild haemorrhagic diathesis . although the effect of unfractionated heparin can be monitored using the activated partial thromboplastin time ( aptt ) , this is not the case for low - molecular - weight heparins ( e.g. tinzaparin and enoxaparin ) that are increasingly used for this indication . to our knowledge , this is the first reported case of intravenous thrombolysis for treatment of acute ischaemic stroke in a haemodialysis patient . the outcome for this patient was favourable ; however , we would advise extreme caution with the use of rtpa ( alteplase ) and treatment delivered on a case - by - case basis .