We describe the use of intravenous thrombolysis with recombinant tissue 
plasminogen activator (IV-rtPA) in a patient with concomitant dabigatran use. A 
64-year-old man with a history of coronary artery disease, pacemaker placement, 
and atrial fibrillation developed acute right arm/face weakness and dysarthria. 
He was unable to list his home medications. His platelet count was 167 × 10(9)/L 
(normal 150-399 × 10(9)/L), and his activated partial thromboplastin time (aPTT) 
was 37.6 seconds (normal 24.0-33.0 seconds). His international normalized ratio 
(INR) was 1.1. He received IV-rtPA at 3 hours and 25 minutes after the onset of 
symptoms. After IV-rtPA was administered, it was discovered that the patient had 
been taking dabigatran for 2 months. After IV-rtPA, the patient developed severe 
superficial left arm ecchymoses but remained without cerebral complications. On 
poststroke day 1, his fibrinogen level was low at 63 mg % (normal 190-395 mg %), 
his aPTT was normal at 33, and his INR was elevated at 1.72 but decreased to 
1.18 on the following day. Repeat computed tomographic imaging of his brain 
confirmed a left middle cerebral artery ischemic cortical infarct. We report a 
case of an acute stroke patient taking dabigatran who received IV-rtPA. In the 
acute stroke setting, clinicians should be aware of the increasing use of 
dabigatran in patients with atrial fibrillation when considering IV-rtPA. 
Although aPTT does not provide a linear response to dabigatran therapy, the 
presence of a completely normal PTT may exclude therapeutic dabigatran 
anticoagulation.