Post-Ablation Stroke Despite NOAC Use: Successful Reperfusion Therapy After Dabigatran Reversal with Incidental Discovery of a Large MCA Aneurysm—A Case Report

<b>Background:</b> Catheter ablation is an established rhythm-control strategy for atrial fibrillation (AF), yet peri-procedural embolic stroke may still occur despite uninterrupted NOAC therapy. <b>Case presentation:</b> A 49-year-old woman on dabigatran developed acute ischemic stroke three days after AF ablation, presenting with left hemiparesis and dysarthria. Idarucizumab (5 g) enabled safe intravenous thrombolysis followed by emergency endovascular thrombectomy (EVT), achieving complete recanalization (mTICI 3). Angiography revealed an incidental 7 mm right MCA aneurysm at the occlusion site. Dabigatran was resumed on day 4, and one month later, the aneurysm was successfully treated with stent-assisted coil embolization. She remained asymptomatic at two months. <b>Conclusions:</b> This case illustrates how idarucizumab reversal expands reperfusion options by enabling both IVT and EVT in NOAC-treated patients and highlights the diagnostic role of EVT in revealing underlying vascular pathology, emphasizing the need for individualized post-procedural antithrombotic management.