A 68-year-old female patient presented to the emergency department with left-sided weakness. Tissue plasminogen activator (tPA) was started for stroke, however, the patient was later found to have a type A intramural hematoma (IMH). TPA was subsequently discontinued. She was hemodynamically stable and was treated medically due to the risk of bleeding from tPA. Fortunately, the patient had a complete neurological recovery. She underwent an aortic repair 6 weeks after initial presentation and was discharged home without any complications. Aortic dissection and IMH should always be in the differential diagnosis when treating patients with signs of cerebral ischemia. This is the first documented case of accidental administration of tPA in a patient with intramural hematoma (IMH), and illustrates a successful case of delayed surgical repair for high risk IMH in patients recovering from cerebral ischemia.