Background Despite receiving anticoagulation for primary or secondary prevention for atrial fibrillation, new embolic events may occur. Current stroke guidelines contraindicate the use of thrombolysis if oral anticoagulants are used within 48 hours of symptom onset. Idarucizumab may be an alternative for patients receiving dabigatran with an acute stroke when alteplase is indicated. We present a series of four cases of patients who received idarucizumab in neurological emergencies in a middle-income country in Latin America. Methods Using the national pharmacologic surveillance data, we retrospectively collected the cases of idarucizumab used in acute stroke, including retinal thrombosis in Colombia between 2018 and 2020. Results Four male patients with atrial fibrillation received thrombolysis for acute stroke, and two of them received mechanical thrombectomy. No major complications during hospitalization were present. One of the patients that received combined therapy presented with hematuria; the other patient that received thrombolysis presented with groin hematoma, but none required transfusion. All had favorable mRS at discharge and 90-day follow-up. Conclusion The use of thrombolysis after reversal with idarucizumab in patients with ischemic stroke is safe. Our patients presented favorable mRS at discharge and 90-day follow-up. The low number of cases is related to the poor availability of idarucizumab. Only 11 hospitals in 5 cities have storage of the medication. Stronger public policies are needed to guarantee optimal stroke treatment in patients with atrial fibrillation receiving anticoagulation, including access to reversal and reperfusion therapies to reduce further disability, especially in a middle-income country such as Colombia.