Objectives Idarucizumab is a humanised monoclonal antibody fragment developed to reverse the anticoagulant effects of dabigatran. In patients presenting with acute ischaemic stroke, it is not yet clear if reversing dabigatran with idarucizumab prior to intravenous alteplase and/or clot retrieval is safe.

Methods All New Zealand patients treated with intravenous alteplase must be entered into a national thrombolysis database. Leading stroke physicians from all hospitals maintaining the database were asked to identify any patients treated with idarucizumab prior to intravenous alteplase/clot retrieval between August and November 2016.

Results Idarucizumab was used in seven patients (mean (SD) age of 65 (11) years) with a median stroke onset to idarucizumab time of 180 (range 137–273) minutes. Six patients were treated with intravenous alteplase, one of whom went on to have clot retrieval, and one was treated with clot retrieval alone. None of the seven patients had a thrombotic complication following idarucizumab. At day 90, five patients were living at home, one who developed intracranial haemorrhage following intravenous alteplase required nursing home care, and one died from the complications of cerebral oedema.

Conclusions This study suggests that idarucizumab can safely reverse the effects of dabigatran prior to intravenous alteplase/clot retrieval in patients presenting with acute ischaemic stroke, and can do so in a timely manner despite needing to wait for the results of a coagulation screen.